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UNITED STATES OF AMERICA. 



A PLEA 



CURE OF RUPTURE 



THE PATHOLOGY OF THE SUBCUTANEOUS 

OPERATION BY INJECTION FOR 

THE CURE OF HERNIA. 



/BY 

JOSEPH II. WAftREN, A.M., M.D., 

MEMBER OF THE BRITISH MEDICAL ASSOCIATION, MEMBER OF THE AMERICAN 

MEDICAL ASSOCIATION (JUDICIARY COUNCIL) , HONORARY MEMBER OF 

THE VERMONT STATE MEDICAL SOCIETY, MEMBER OF THE 

MASSACHUSETTS MEDICAL SOCIETY, FORMERLY 

SURGEON AND MEDICAL DIRECTOR IN 

THE UNITED STATES ARMY. 



£ 






Op- wash^ c 



BOSTON: 
JAMES R. OSGOOD AND COMPANY. 

LONDON: 
J. AND A. CHURCHILL. 

1884. 



Copyright, 1883, 
By JOSEPH H. WARREN". 



All rights reserved. 



FRANKLIN PRESS : 

RAND, AVERT, AND COMPANY, 

BOSTON. 



CONTENTS. 



i. 

Inflammation and its Relation to Tissue Repair ... 7 

II. 

Permanent Cuke of Hernia by Subcutaneous Injection . 24 

III. 

History of My Connection with the Method of Subcutane- 
ous Injection for Hernia 62 

IV. 

A Plea for Operative Measures for the Relief and Cure 

of Hernia 80 

V. 

The Proper Fitting and Wearing of a Truss .... 91 

VI. 

Causation of Hernia. Differential Diagnostic Tables. 
t Form for Report of Cases. Table of Cases of Two 

Years' Standing . .97 



PREFACE. 



The new conformateur for measuring and showing 
accurately the contour of hernia, and deformities, such 
as fractured bones, tumors, etc., as well as the paper 
on causation of hernia, were contributed to this mono- 
graph by C. Everett Warren, A.B., M.D., of Boston. 
The paper on the proper fitting and wearing of a truss 
was contributed by W. Everett Smith, A.B., M.D., of 
Framingham, Mass. Besides, these contributions I 
have received cheerful co-operation from both of these 
gentlemen in preparing this work. I am greatly in- 
debted to George Tiemann & Co. and John Reynders 
& Co. of New York for illustrations of my instruments ; 
also to Mr. Richard H. Kimball, chemist, of Cambridge, 
Mass., for his careful and accurate description of the 
method of preparing the various formulas used in my 
operations. The paper, " A Plea for Operative Measures 
for the Relief and Cure of Hernia," which was prepared 
for reading before the meeting at Liverpool of the Brit- 
ish Medical Association, is here published, with very 
slight alterations, as it originally appeared in the Asso- 
ciation's journal. 



6 PREFACE. 

The portion of this monograph that treats of tissue 
repair was prepared for presentation before the Suffolk 
District Medical Society some two years ago, but was 
not read, owing to sickness. Some of my personal 
friends urged me to publish the article, as it contained 
matter of interest and value, hitherto unknown, con- 
cerning the operation for the cure of hernia by the 
method of subcutaneous injection. Jt is here reprinted 
from the Glasgow " Medical Journal " of April and May, 
1883, together with a brief resume of the modus ope- 
randi of the subcutaneous method, intended to assist 
those who have not become familiar with the operation 
as it is presented in my " Treatise on Hernia," second 
edition, published by James R. Osgood & Co., Boston, 
Mass., U.S.A., and Messrs. J. & A. Churchill, London. 

To this I have added a paper given by me before the 
American Medical Association in June, 1883, and other 
matter of interest to the profession. 

JOS. II. WARREN. 
51 Union Park, Boston, Mass. 



A PLEA FOR THE CURE OF RUPTURE; 

OK, 

THE PATHOLOGY OF THE SUBCUTANEOUS OPERATION 
BY INJECTION FOR THE CURE OF HERNIA. 



PART I. 



INFLAMMATION AND ITS RELATION TO 
TISSUE REPAIR. 



"The subject of irritation being the foundation of surgical science, 
you must carefully study and clearly understand it before you can 
expect to know the principles of your profession, or be qualified to prac- 
tise it creditably to yourselves or with advantage to those who may 
place themselves under your care." — Sir Astlev Coofer, Lectures on 
Surgery. 

Theories of Inflammation. — "No topic in medi- 
cine has been the subject of so much research and 
speculation as the nature of inflammation ; but even 
at the present time it is impossible to give a com- 
plete and correct definition of inflammation from a 
pathological or an etiological stand-point" (Flint). 
The word originated when there were no true 
pathological ideas ; yet even the oldest observers 



5 A PLEA FOR THE CURE OF RUPTURE. 

regarded the process as an intense increase of the 
normal physiological processes, — a "disturbance 
of nutrition " (Virchow). The idea, however, that 
the classic symptoms, tumor, rubor, color, dolor, — 
pain, heat, redness, and swelling, - — are the true 
characteristics of inflammation, has unfortunately 
become so deeply rooted that it may seem to some 
almost absurd to claim that the inflammatory pro- 
cesses may be present in tissues even when the 
local gross symptoms are absent. The modern his- 
tological idea of inflammation as a purely regenera- 
tive process, which directly or indirectly replaces the 
loss of substance, cannot, indeed, be rigidly sepa- 
rated from the classical idea of an intense irritation 
which tends directly or indirectly to a destructive 
process. The difference is only in the degree of 
irritation ; but this is a difference so fundamental 
and important for the proper understanding of the 
processes of tissue repair, that it must be made 
emphatic. The word "inflammation" is, however, 
in such common use, that it would be foolish to 
attempt to discard it. I shall therefore, for the 
clearness of discussion, designate the salutary pro- 
cess regenerative inflammation, and reserve for 
the intense process the term classic inflammation. 



A PLEA FOR THE CURE OF RUPTURE. \) 

According to John Hunter, and to the modern 
French surgeons, the essential phenomena are 
referable to the vascular system. Plastic lymph — 
that is, a thin opalescent layer containing fibrin and 
red and white blood-corpuscles — is derived from 
the vessels by exudation, and is susceptible of or- 
ganization, and of the formation of the different 
tissues of the body. Recently this theory has been 
revived in a modified form by Cohnheim, who 
explains the process by an exudation of serum and 
white corpuscles, and a coagulation of a fibrin oge- 
nous substance contained in the exuded serum. 

Plastic-Lymph Theory. — The former ideas of 
this effused lymph divided it into two distinct 
classes, which have received various names : — 

Healthy (Clarke) . Unhealthy. 

Plastic (Williams). Aplastic. 

Fibrinous (Paget). Corpuscular. 

Fibrinous (Rokitansky). Croupous. 

Coagulable. Degenerative. 

Adhesive. Suppurative. 

According to this theory, which held undisputed 
sway for many years, and which is even at the 
present day often confounded with later and more 
exact theories, there are two elements in the exu- 



10 A PLICA FOE THE CUKE OF RUPTURE. 

elation — namely, fibrin and corpuscles — which 
control the development of this lymph, so called. 
In proportion as fibrin is abundant, so will the 
tendency to organization and adhesive inflammation 
prevail ; but, in proportion as the blood-corpuscles 
are abundant, so will the tendency to degeneration 
and suppurative inflammation prevail. Ever since 
the time of Bichat. there has been a general im- 
pression that each tissue has its proper mode and 
product of inflammation, serous membranes being 
prone to fibrinous exudations, mucous to suppurative or 
corpuscular, and cellular to both fibrinous and corpus- 
cular. Slight inflammations also were believed to 
be almost always corpuscular, while the more acute 
and active were fibrinous. 

Repair by means of nucleated cells was said to be 
observed in granulations, in inflammatory adhesions 
(either in serous sacs or in healing by first inten- 
tion), in inflammatory indurations, and in certain 
naturally developed connective tissues. The pro- 
cess was actually described by Schwann, who saw 
the nuclei become more distinct, and then have 
several nucleoli appear in them. The cells, more- 
over, became granular and elongated, and grouped 
together in clusters or filaments. 



A PLEA FOR THE CUKE OP RUPTURE. 11 

Development of fibrous tissue was supposed to 
take place by means of a blastema, and was best 
seen in subcutaneous wounds. 1 It was the only 
mode of formation of connective tissue recognized 
by Henle. 2 A similar process is described by 
Reichert, Zwicky, and Gerlach. The first thing 
noticed after the exudation was a quantity of 
molecular or finely shaded substance like homoge- 
neous or dotted fibrin. At first there were no nuclei 
or cells apparent ; but later they began to appear as 
oval bodies, soon becoming elongated. They had 
clear contents and no nucleoli, and were very 
firmly embedded in the blastema. These nuclei 
underwent very little change, except to elongate, 
and possibly to become irregular in outline ; but 
the blastema assumed a more and more filamentous 
appearance, and finally a filamentous structure. 
Henle, indeed, supposed the nuclei to be made into 
fibres ; but of this there does not seem to be proof. 
The exudation of cells which, of course, to a 
limited extent accompanied this blastema, was con- 
sidered to have no share in the healing process. 
In fact, the more abundant the cell-exudation, the 
longer the inflammation ; and the longer the in- 
flammation, the less speedy and perfect was the 

1 Paget; Surgical Patholog}'. 2 Allgenieine Anatonrie. 



1*2 A PLEA FOK THE CURE OF RUPTURE. 

repair. The theory of a blastema is now, however, 
antiquated, and believed to be histologically incor- 
rect. 

Proliferation Theory. — Virchow, on the con- 
trary, rejecting Hunter's doctrine, maintained that 
the chief effect of an inflammation is an increased 
function and nutritive activity of cells in the solid 
tissues outside the blood-vessels, and that hyper- 
emia and exudations from the blood are secondary 
changes. This theory rests on a proliferation from 
pre-existing fixed cells, in accordance with the law, 
" Omnis cellahi e cellula" and is to-day supported 
by Strieker, Burdon Sanderson, and their school. 

Cohnheims Theory. — The discovery by Reckling- 
hausen, in 1863, of wandering cells in the tissues, 
rendered Virchow's theory 1 somewhat doubtful, 
while a new era was introduced in the history of 
inflammation by Cohnheim's discovery 2 of the emi- 
gration of white blood-corpuscles. This migration 
of cells had been first observed by Dr. W. Addison, 3 
and again by Dr. A. Waller; 4 but their isolated 
observations were little thought of, and soon forgot- 

1 Uber EiterundBindegewebskorperchen. — Virch. Archiv., xxviii. 

2 Uber Entziindung und Eiterung. — Virch. Archiv., xl., 1806. 

3 Experimental and Practical Researches on Inflammation. — 
Trans. Prov. Med. Assoc, 1842. 

4 Phil. Magazine, vol. xxxix., 1846. 



A PLEA FOR THE CURE OF RUPTURE. 13 

ten. This is not the place to detail the theory of 
Cohnheim, which is already accepted as scientifi- 
cally accurate, nor to discuss the exact method of 
the emigration of these cells. The former is too 
well known to need description ; the latter is still a 
question of some dispute. 

That the greater number of these cells is un- 
doubtedly the result of an emigration of these white 
blood-corpuscles is, however, by no means incom- 
patible with the theory that the fixed cells of con- 
nective tissue become amoeboid, proliferate, and 
produce other cells ; that is, take part in the re- 
generative process. 

Organization. — The nature of this cell activity 
is conservative. Whenever a living tissue is irri- 
tated, provided the irritation be insufficient to 
destroy the vitality of the part, an inflammatory 
process is set up which tends to recovery, and is 
indeed the one process indispensable and necessary 
for recovery. These cells, which have been pro- 
duced by a process of emigration, or of proliferation, 
or by both processes combined, do not, however, 
remain stationary and inactive. They tend to 
become either organized into higher structures, or 
disorganized into a state of fatty degeneration and 



14 A PLEA FOR THE CURE OF RUPTURE. 

absorption, or else a state of suppuration. The 
tendency to undergo a progressive organization into 
higher tissues will vary : — 

1 . With the tissue involved. 

2. The condition of the individual. 

3. The degree of inflammation. 

In non-vascular tissues, such as cartilage, tendon, 
and the cornea, exudation from the neighboring 
vessels is limited, and hence the effusion is small in 
amount ; while in vascular areas, as bone and the 
loose connective tissues, the inflammatory effusion 
is more abundant. " The more intense, however, 
the inflammation, the more abortive are the young 
cells, and the less their tendency to form a perma- 
nent tissue " (Green). 

Resolution. — On the other hand, if the injury to 
the tissues be very slight, the inflammation may 
gradually subside, the emigration cease, the young 
cells become fatty degenerated, and little by little 
pass into the lymphatic circulation, and leave the 
tissue in its normal condition. 

Suppuration. — If, however, the irritation be so 
severe or prolonged as to prevent either resolution 
or organization, or if the condition of the individual 
be unfit to produce a favorable termination of tissue 



A PLEA FOR THE CURE OF RUPTURE. 15 

lesions, the cells will accumulate in such numbers 
and so degenerate as to become purulent in their 
nature and behavior. In regard to the influence of 
constitutional peculiarities over the tissue changes 
in inflammation, clinical evidence is not wanting. 
The taint of various diatheses, the scrofulous so 
called, the syphilitic, cancerous, and tuberculous are 
well known to impart an abnormal susceptibility of 
certain tissues to injury or irritation, and a pecul- 
iarity in the products and course of the inflammation 
which such irritation produces. There is. little or 
no tendency to the organization of healthy new 
growth. From facts such as these the conclusions 
have been drawn, that in young persons, and in per- 
sons of strong constitution, we may, as a rule, look 
for a good and permanent repair of tissue lesions, a 
so-called " adhesive inflammation" but that in the old 
and cachectic we may expect a suppuration. 

The deleterious influence which pus exercises 
upon surrounding tissues and the process of repair 
is also a well-known clinical fact. Pus, which has 
remained for any length of time in the tissues, un- 
dergoes certain changes. It may undergo fatty 
metamorphosis, and thus, by absorption, poison the 
system. At any rate "the pus- corpuscles appear 



16 A PLEA FOR THE CURE OF RUPTURE. 

to be endowed with the power of absorbing the 
tissues with which they come in contact, or at all 
events of causing their liquefaction : " hence the 
softening and disintegration of the tissues which 
constitute such a destructive element in intense in- 
flammation. 

Subcutaneous Healing. — The problem of modern 
surgery has been to create a sufficient amount of 
inflammation to produce the amount of exudation 
requisite to insure tissue organization, but not to 
exceed this sufficient amount of exudation, and so 
produce an intense inflammation with all its puru- 
lent sequela?. This problem has been solved by 
the introduction by Strohmeyer and Dieffenbach 
of the method of subcutaneous operations. In fact, 
the fundamental and only essential principle of 
Listerism is the exclusion of outside foreign ma- 
terial ; that is, the transformation of an open wound 
into a wound practically subcutaneous. 

The advantage of a subcutaneous over an open 
wound is this : the former heals by primary adhesion, 
— the " First Intention" of Hunter, — other condi- 
tions of the patient being favorable ; while the 
latter, under the same conditions, might heal by 
primary, but would probably heal by secondary ad- 



A PLEA FOR THE CURE OF RUPTURE. 17 

hesion, — the "Second Intention" of Hunter; that 
is, by granulation and suppuration. 

What, then, are the processes we observe in 
union by primary adhesion after a subcutaneous 
operation ? As a result of the operation the con- 
ditions of the vascular circulation have been altered. 
The liquor sanguinis which has thus escaped coagu- 
lates within twenty-four hours, on account of the 
fibrin elements it contains, and imprisons numbers 
of white corpuscles. The stiffening of this intercel- 
lular substance explains why the union is so firm as 
to unite without sutures. The cells in the wound 
gradually become spindle-shaped, and assume more 
and more the form of normal fibrous connective 
tissue, becoming stellate and anastomosing into a 
firm network. 1 However rapid the union may be, 
it is not so simple as some authors have thought. 2 

Formerly, under the old plasma theory, as I have 
previously said, it was supposed that the fibrin 
which was exuded in the liquor sanguinis was 
changed directly into fibrous tissue. Schwann 
assumed that there existed originally spindle cells 

1 Kolliker describes the white fibrous tissue as formed from the 
coalescence of fusiform cells, and the yellow elastic fibres as developed 
from the stellate branching corpuscles, which Yirchowhas called con- 
nective-tissue corpuscles. 

2 Cornil and Ranvier: Path. Histology, p. 71. 



18 A PLEA FOR THE CURE OF RUPTURE. 

from which bundles of connective tissue were 
developed by a splitting of the body of the cell. 
Henle thought that originally there were no 
cells, but only nuclei, and that the fibres which 
afterward appeared were produced by direct 
fibrillation of the blastema, while the nuclei grad- 
ually became elongated, and coalesced to form 
longitudinal fibres (Kernfasern, — nucleus fibres). 
Reichert contended that there were both cells and 
intercellular substance, but said, " The intercellular 
substance fibres were a false interpretation of 
an optical image." Virchow, with Schwann, and 
against Henle, believes that spindle-shaped cells in- 
disputably exist, and with Henle and Reichert, and 
against Schwann, that a splitting-up of the cells 
into fibres does not occur, but that a previously 
homogeneous or mucous intercellular substance 
becomes fibrillated in some way, while the young 
cells maintain their integrity throughout. It is 
unnecessary to say that this is a manifest inconsis- 
tency in Virchow's " Cellular Pathology." 

Max Schultze of Germany, Beal of England, 
and Leidy and Tyson of America believe that the 
intercellular substance originates by a change in 
the nucleus at its periphery, and by a pushing-off 



A PLEA FOR THE CURE OF RUPTURE. 19 

of this formed material from the cell. This theory 
seems to be the most consistent with observation, 
and is the one that is generally adopted at the 
present day. 1 

The intercellular substance having thus been 
formed has yet to undergo other processes before 
it reaches a stable state. The spindle cells assume 
the flat shape of connective-tissue corpuscles, and 
coalescing into bundles or fasciculi, with the nuclei 
alone remaining, gradually render the newly 
formed tissue firmer and denser by the contractile 
power of fibrous tissue, until at last it is as solid 
and compact as normal tissue, and remains stable 
in this state. That this contraction and stability 
of the new fibrous tissues is not merely theoretical, 
but is emphatically proved by clinical experience, 
will be later clearly shown. 

Healing by Granulation or Suppuration. — All 
wounds do not, however, heal by primary adhesion, 
and especially is this statement true of wounds 
where open incisions are made through the cuta- 
neous tissues to the deeper parts. The process 
of repair in such wounds is rarely other than by 
secondary adhesion or by suppuration. Histologi- 
cally the process is the same in character as in 

1 Tyson: The Cell Doctrine, p. 141. 



20 A PLEA FOR THE CURE OF RUPTURE. 

repair by primary adhesion ; but it differs greatly 
in degree. The cicatrization also is slower, and the 
tissue may experience the divers accidents incident 
to suppurating wounds. When, however, inflam- 
mation is artificially produced in order to gain a 
regenerative new formation, this difference be- 
comes so important as to throw the two processes 
of healing into distinct classes, — one of which, the 
primary adhesion, attains the end for which it is 
seeking ; the other, the secondary adhesion, tends 
to defeat it. Whereas in the subcutaneous opera- 
tion we had no external opening, in this case we 
have an open, gaping wound. The flaps are red- 
dened, swollen, and sensitive to the touch, while 
over their whole extent is seen a number of yel- 
lowish or grayish particles. These particles are 
dead bits of tissue still adherent to the living por- 
tion. Particularly is this the case, says Billroth, 1 
if tendons, or fasciae, or the cortical substances of 
bones have been injured, and if the wound is upon 
old or debilitated persons or badly nourished 
children. Under such circumstances as these, the 
process of repair will be much prolonged. Until, 
then, these irritating bits of dead tissue " clean 

1 General Surgical Pathology and Therapeutics. Amer. Ed. Sec. 
vii., p. 7. 



A PLEA FOR THE CURE OF RUPTURE. 21 

off," no active process of repair can begin. Sup- 
posing repair to have begun, we shall find the 
wound gradually filling up from the bottom with 
a mass of cells or granulation tissue. These gran- 
ulations are covered all the time, however, with a 
fluid which becomes thick, pure yellow, and of 
creamy consistence. 

This is pus, and in this lies the danger and the 
weakness of the granulation process. In most 
cases more or less of this pus will die from 
insufficient blood-supply. The cells escaping from 
the vessels remain upon the surface of the tender 
granulations, bathing them in a soft gelatinous fluid. 
This fluid tends to disintegration and re-absorption 
into the body through numerous lymph channels, 
and at the same time re- acts upon the newly 
formed granulations beneath it. Some of the 
cells gradually become fatty and granular, and are 
absorbed, while others undergo the change into 
connective tissue already described. At best the 
process is a long and tedious one compared with 
subcutaneous processes ; and the danger is always 
an immediate one, that in place of organization 
a suppuration may destroy what little has been 
built up. 



22 A PLEA FOR THE CURE OF RUPTURE. 

Laws governing Repair. — From all that has 
been said, six important laws controlling the trans- 
formation of the inflamed tissue may be legiti- 
mately deduced : — 

1. A certain amount of inflammation is neces- 
sary for repair. 

2. Inflammation and repair, although bearing 
the relation of cause and effect, are antagonistic in 
their processes. In other words, repair does not, 
and cannot, begin until inflammation subsides ; and 
the longer and the more severe the inflammation, 
the more weakened will be the tissues, and the less 
able will they be to organize into higher develop- 
ment. 

It is true John Hunter claimed that " injuries 
in which the parts do not communicate externally 
seldom inflame, while those which have an external 
communication commonly both inflame and sup- 
purate." Nor is it inconsistent in the least with 
what I have just laid down as a general axiom : 
on the contrary, it rather corroborates it. Viewed 
with the naked eye the gross appearances of a 
subcutaneous wound are those of a total absence 
of inflammation ; but the process that is going on 
beneath the surface, and at the seat of irritation, 



A PLEA FOR THE CURE OF RUPTURE. 23 

is essentially and histologically inflammatory. If, 
however, this inflammation becomes more intense 
than nature requires for the healing process, it 
passes beyond a mere physiological activity of cells, 
and reveals itself by the classical signs of inflamma- 
tion, — Rubor et tumor, cum colore et dolor e. 

3. " The processes of repair are identical in all 
tissues, such modifications alone showing them- 
selves as necessarily appertain to the anatomy of 
the tissue, or the special circumstance of its posi- 
tion." x 

4. The essential element of repair is the growth 
of embryonic tissue. 

5. " Whenever artificial or pathological irrita- 
tion has determined a growth of embryonic ele- 
ments, if the irritation cease, this new growth 
always tends to return to the original form of the 
tissue, which served as a matrix." 2 

6. In other words, " whatever may be the origin 
of this embryonic tissue, it has a tendency to re- 
produce the tissue of the region where it is 
seated." 3 

1 Bryant : System of Surgery. 

2 Cornil and Ranvier, p. 72. 3 Ibid. 



24 A PLEA FOR THE CURE OF RUPTURE. 



PART II. 

PERMANENT CURE OF HERNIA BY SUBCU- 
TANEOUS INJECTION. 

Tendinous Irritation. — It is strange that, in view 
of all the logical and scientific thinking of the 
present day, so many erroneous ideas should be 
perpetuated in regard to the permanent cure of 
hernia. Professor Gross, years ago, struck the 
key-note of the subject when he said that the only 
chance of curing this complaint lay in compression 
by a truss, or the inflammation produced by the 
subcutaneous injection of some fluid. Yet how 
little is the pathology of such an operation under- 
stood, even at the present moment, by the great 
majority of medical men ! 

Dr. Heaton 1 ascribed his cures to a method of 
" tendinous irritation' without inflammation, attempt- 
ing thereby to develop a pathology whose chief 

1 Heaton On Rupture, edited by Davenport. 



A PLEA FOR THE CURE OF RUPTURE. 25 

element is the total absence of all pathology ; and 
on this account some operators have expected a 
miraculous cure to take place, but, finding that the 
same laws govern this operation as govern all 
other surgical operations, have pretended to feel 
themselves lucky if they got any favorable result 
whatever from their labors. My object in this 
paper is to show that the operation has no peculiar 
pathology in it, that modern pathology corrobo- 
rates at every step the teachings of clinical ex- 
perience in the operation, and that those who still 
persist in assigning the cures by subcutaneous in- 
jection to some peculiar "tendinous irritation" 
without inflammation, are forgetful of their scien- 
tific training, and regardless of their reputation for 
professional consistency. 

This " tendinous irritation," so called, is an ab- 
solute myth. In reality we have a regenerative in- 
flammation, the pathology of which I have already 
clearly described. Because the operation is so 
completely subcutaneous, this regenerative inflam- 
mation does not run on into the classic inflamma- 
tion, as I have called it, nor develop granulation 
tissue. This is the only rational method of closing 
the hernial canal. On the other hand, all other 



26 A PLEA FOR THE CURE OF RUPTURE. 

operations for hernia fail in good results, because 
the intense inflammation which they inevitably tend 
to excite destroys their good intentions. 

Wood's operation — about which, of late years, 
we have heard so much — has in it, indeed, two ele- 
ments of failure. First, it seeks to draw together 
fibrous bands which are hard, firm, and immovable. 
This operation in itself excites theoretically very 
little local inflammation, and therefore there is no 
obvious reason that I can see why adhesion be- 
tween these bands, so as to close the hernial canal, 
ever should take place. It is like operating for a 
lacerated cervix, or hare-lip, without paring the 
gaping edges. On this account I suggested to Dr. 
Henry O. Marcy of Boston, U.S.A., the feasibility 
of freshening the fibrous edges of the hernial 
opening before occluding the canal by carbolized 
ligatures. This method, I understand, he has at- 
tempted ; and I should think it offers a more 
rational chance of success than previous treatments 
by ligature. 

The second objection to Wood's operation is, 
that, when performed in the ordinary manner by 
wire sutures, it depends for its cure upon a process 
of granulation which, from its protracted duration, 



A PLEA FOR THE CUKE OF RUPTURE. 27 

is fatal to a cure of hernia, and, from its danger of 
producing an iliac abscess or a general pyaemia, 
may be fatal to the individual. When, however, 
operations which involve external incisions are per- 
formed under strictly antiseptic precautions, which 
reduce them theoretically to subcutaneous opera- 
tions, the results are far more favorable than when 
the wounds are allowed to heal in the ordinary 
manner. This fact I have amply shown in my 
description of Czerny's method of operation in my 
" Practical Treatise on Hernia." * 

Closure of the Sac. — The statement has been 
made that " the essence of success in hernial oper- 
ations consists in setting up peritonitis in the sac, 
and in the ability to control the inflammation when 
started." 2 This, of course, can apply only to cases 
of congenital hernia, and even in these cases is 
true only in a very modified manner. The essen- 
tial element of success in the cure of congenital 
hernia, as in the cure of acquired hernia, is the 
closure of the hernial rings and hernial canal. It is 
true that such closure will at the same time obliter- 

1 Treatise on Hernia. Second edition. Boston: J. R. Osgood & 
Co., 1882. 

2 Dr. D. W. Cheever in Boston Med. and Surg. Jour., 12th Jan., 
1882. 



28 A PLEA FOR THE CURE OF RUPTURE. 

ate the unclosed pouch of peritoneum ; but, if this 
pouch be the only thing that is occluded, there is 
nothing to prevent another protrusion of the peri- 
toneum through the canal, which is still unclosed, 
forming what is termed the " acquired congenital 
form of hernia," " the encysted hernia of Sir Astley 
Cooper," or the " infantile hernia of Hey." 1 But, 
even supposing that a limited degree of local peri- 
tonitis is the result of our treatment, we do not fear 
the result. On the contrary, we are rather rejoiced 
that it should occur, since it tends to complete the 
cure by causing adhesion between the visceral 
layers of the sac, and also between the parietal 
layer and the fasciae forming the hernial canal. 
The time has been when local peritonitis was the 
bugbear of abdominal surgery ; but that has long 
ago passed away, as the many successful abdominal 
sections and ovariotomies bear witness. Certainly, 
as bold an operation as any subcutaneous injection 
was recently reported 2 from Dr. H. J. Bigelow's 
practice, where, for an umbilical hernia, the in- 
vaginated sac of the integument was blistered 
successively with tincture of cantharides, liquor 

1 Practical Treatise on Hernia, p. 16. 

2 Boston Med. and Surg Jour., 5th Jan., 1882. 



A PLEA FOR THE CURE OF RUPTURE. 29 

amnionic fortior, and tincture of iodine, to produce 
intense suppuration in hope of a permanent cure. 
One hundred and sixteen days after entrance to 
the hospital, granulations were seen at the neck 
of the inverted sac ; two hundred and two days 
after entrance, the patient was allowed to sit up for 
a short time ; and two hundred and fourteen days 
after entrance, she was dismissed cured, but told 
to wear a truss as a matter of precaution. If the 
obliteration of such an organic plug as this invagi- 
nated hernial sac would not tend to produce local 
peritonitis, I fail to understand what would. 

It has been claimed that this method of pro- 
cedure involved rather a new process of curing 
hernia. As long ago as the times of Ravin, 
Riviere, and Arnauld, position was recommended 
as a cure, while the process of inflaming a foldpf 
invaginated skin is the very method which Gerdy 
and Signoroni practised in 1837, and which Wiirt- 
zer modified. 

Injection of the Sac. — A second error in regard 
to the subcutaneous method of injection is one that 
I have time and again emphatically contradicted. 
The profession will persist in supposing that the 
injection is to be made into the hernial sac, — that 



30 A PLEA FOE THE CURE OF RUPTURE. 

is, into the peritoneal cavity, — and consequently 
expect to see a general peritonitis, and perhaps an 
inflammation of the cord and testis, sympathetic or 
traumatic. This is the method described in most 
of the text-books of surgery ; but certainly a cure 
by such a process would be little short of a miracle. 
If this were the correct theory, we might as well 
expect that a sieve would hold water as that a 
peritoneum would support the pressure of the in- 
testines, constantly forced down by gravity and the 
contraction of the abdominal muscles into a per- 
fectly open hernial canal. I say it once for all, 
the tissues to be irritated and organized into 
fibrous structure are the tendons and fasciae form- 
ing and comprising both the internal and external 
hernia] rings, together with the whole length of 
the hernial canal, and that the hernial sac is al- 
ways to be thoroughly reduced before the oper- 
ation whenever it is possible. If, perchance, the 
sac has become adherent to these rings or the 
canal, we can by a very little manipulation, such 
as most surgeons are capable of, lodge the point 
of the syringe between the sac and the borders of 
the canal, and deliver our injection into the fibrous 
tissue and around the hernial sac. As I have 



A PLEA FOR THE CURE OF RUPTURE. 31 

already said, a little inflammation of such a sac is 
not only not to be dreaded, but, on the contrary, 
rather to be desired. 

Action of Quercus Alba. — A third error, and the 
last that I shall notice here, has reference to the 
astringent properties of the quercus alba, which is 
injected. None of the fluids employed by the 
early operators in subcutaneous injections for 
hernia were used with any idea that it was a 
fibrous contraction that was to be sought. On the 
contrary, the very first idea of this method was 
suggested to Velpeau by the injection method of 
curing hydrocele, which was by creating inflamma- 
tion and adhesion. Never, before Heaton, had any 
one ever dreamed that it was to " the astringent 
principles of the injection," producing " a perma- 
nent contraction of the fibrous structures," that we 
must look for our regenerative process, and never 
again may we hear of such pathology. I am not 
surprised when I think of this, that surgeons have 
been sceptical of the benefits resulting from the 
injection method ; but I am surprised when I hear 
medical men of the present day repeating and 
believing such false pathology. 

The operation for the cure of hernia by subcuta- 



32 A PLEA FOR THE CURE OF RUPTURE. 

neous injection is then successful, not because it 
produces a " tendinous irritation," — that is, an im- 
mediate contraction of fibrous tissues,. — but because 
it produces a local inflammation without suppuration. 
This is an important distinction, both as regards 
the theory and as regards the practical success and 
permanence of the operation. All other methods 
have accepted and expected suppuration as an ac- 
companiment of the operative procedure, and have 
not been disappointed when they obtained it. This 
method avoids suppuration, as it would every other 
unfavorable complication. Other methods cannot 
avoid suppuration : this method can, and does avoid 
it when properly performed, and with the proper 
fluids. 1 

As regards the comparative value of the fluids 
that have been used from time to time for injection, 
it is altogether probable that many have failed 
because they were absorbed without producing the 
amount of inflammation necessary to produce a re- 
organization of fibrous tissue. Probably oak-bark is 

1 With the fluid which I have latterly adopted and used in upwards 
of a hundred cases, I have not had a single case of suppuration. 
Among my first few cases, in which I used Heaton's mixture and 
instruments, I had three cases of suppuration, — one severe and two 
slight cases. 



A PLEA FOR THE CURE OF RUPTURE. 33 

specific in its action, because, of all substances not 
destructive to the tissues, it refuses most obstinately 
to be absorbed before the inflammation set up by it, 
the ether and alcohol, shall have caused a sufficient 
cellular activity to render the regeneration of the 
normal fibrous tissue reasonably certain. All that 
by any possibility its astringent properties can do 
is to aid, perhaps, in keeping the fibrous pillars of 
the hernial rings somewhat in their normal posi- 
tion until the new tissue is properly organized into 
a firm growth. 

Is this New Fibrous Tissue Stable ? — Thus far 
we have considered the cure of hernia from the 
theoretical stand-point of the nature of the inflam- 
inatory process. What evidence can be adduced 
that the new fibrous tissue, which is formed by this 
regenerative inflammation, will be permanent, and 
not readily absorbed ? The proof that can be offered 
upon this question is very positive and twofold in its 
nature, — first, the evidence drawn from analogy ; 
second, the unmistakable evidence of clinical expe- 
rience. 

Proof by Analogy. — By the evidence afforded 
by analogy I mean the history of the permanence 
of fibrous new growths and adhesions produced by 



o4 A PLEA FOR THE CURE OF RUPTURE. 

inflammation in other organs and tissues of the 
body, besides the hernial rings. In examining 
these fibrous tissues I shall use for my chief 
reference the latest and most authoritative work 
on pathological histology. I refer to Cornil and 
Ranvier. 

Let us first consider arteries 1 and veins. 2 Cer- 
tainly, every surgeon has abundant opportunity to 
see the inflammatory processes that occur in these 
tissues by the re-organization which takes place in 
vessels that have been ligatured. The whole safety 
of the recovery depends upon the knowledge that 
the new tissue here formed will not become ab- 
sorbed, but will endure as long as the arteries 
endure. Not only, however, is the growth of per- 
manent tissue seen in traumatic inflammation, it is 
seen also in acute endarteritis and in periateritis, 
occluding the vessels, and hindering or even arrest- 
ing the circulation of the blood. The same perma- 
nent new tissue is seen also in chronic endocarditis 3 
and in valvulitis? in which latter process the chordae 
tendinis of the auriculo-ventricular valves are also 
indurated and shortened. When, however, a sup- 

1 Cornil and Ranvier, p. 307. 2 Ibid., p. 339. 

3 Ibid., p. 300. 4 Ibid., p. 303. 



A PLEA FOR THE CURE OF RUPTURE. 85 

puration occurs in or around these structures, the 
process is well known to be destructive and absorp- 
tive. 

Inflammatory new growth of tissue, which is 
remarkably permanent and firm, is seen also in 
chronic mastitis? chronic adenitis? chronic bronchi- 
tis? oesophagitis 4 " (where the resulting stenosis is 
often extreme), in cicatrization of ulcers of the stom- 
ach? producing the hour-glass constriction, and in 
cicatrization of intestinal ulcers, whether tubercular, 
syphilitic, typhoid, or dysenteric. The result of 
such fibrous cicatrization is " obstinate constipation, 
and even complete obstruction of bowels." 6 In 
cirrhosis of the liver? and in fibroid phthisis, so 
called, 8 the same inflammatory fibrous growth, from 
its remarkable persistence, calls forth the gravest 
prognosis. In the fibrous form of interstitial ne- 
phritis? the characteristic and incurable lesion is 
the formation of new connective tissue, embryonic 
or fibrous, and atrophy of the secreting glands. Not 

1 Cornil and Ranvier, p. 707. 2 Ibid., p. 353. 3 Ibid., p. 405. 
4 ibid., p. 459. 5 Ibid., p. 471. 

6 J. J. Woodward in Med. and Surg. Hist, of War of Rebellion. 
Med. Vol., Part ii., vol. ii., p. 503. 

7 Flint: Principles and Practice of Med. 3d Ed., p. 607. 

8 Ibid., p. 223. 9 Cornil and Ranvier, p. 631. 



36 A PLEA FOR THE CURE OF RUPTURE. 

infrequently as the result of a simple orchitis 1 do 
indurations, consisting of hard and contracting cica- 
tricial tissue, compress the excretory ducts of the 
testicle, causing a narrowing or entire obliteration 
of them, and consequently a suppression of the 
functions and an atrophy of the testicle. 

The time has been when inflammation of the 
urethra producing stricture was considered a special 
type ; but now I think it is agreed that the type is 
common to all fibrous tissues, since stricture may 
occur not only as the result of gonorrhoea, but also 
before puberty, and as the result of a traumatic 
injury. The locality of a stricture is important in 
relation to its pathology. By far the majority of 
cases occur at the junction of the spongy and 
membranous portions of the urethra, where the 
surrounding connective tissue is loose and compar- 
atively superficial. As, however, we approach the 
prostatic end of the membranous portion, where 
the connective tissue is dense and firm and deeply 
seated, stricture becomes rare in occurrence. The 
rule seems to be that stricture occurs most readily 
where the opportunity for the deposit and organi- 
zation of inflammatory material is the greatest. 

1 Cornil and Ranvier, p. 660. 



A PLEA FOR THE CURE OF RUPTURE. 37 

This is precisely the pathology we have presented 
in regard to the permanent cure of hernia by sub- 
cutaneous injection. 

The results of inflammation of serous membranes 1 
are well known to every physician who has ever 
made or seen an autopsy. Few indeed are the 
subjects who do not present adhesions of the pleura?, 
either band-like or even obliterating the pleural 
cavity. Sometimes these bands are seen in the 
pericardial sac, 2 while after the various forms of 
abdominal inflammation cases are by no means rare 
where the whole length of the intestines, with all 
the abdominal organs, has been fused into one solid 
mass by firm and persistent adhesions. More com- 
mon indeed are the firm local adhesions resulting 
from chronic ovaritis, salpingitis, and perimetritis. 

In arthritis, 2, whether acute or chronic, traumatic 
or rheumatic, the synovial membrane is not the 
only part affected ; but even in slight attacks a 
modification of the diarthrodial cartilage is con- 
stantly seen. The histological process is very read- 
ily appreciated by the microscope, while many a 
sufferer can testify that the thickening and stiffen- 
ing of rheumatic joints is one of the most obstinate 

1 Cornil and Ranvier, p. 259. 2 Ibid., p. 290. 3 Ibid., p. 228. 



38 A PLEA FOR THE CUKE OF RUPTURE. 

of tissue lesions to overcome. On the other hand, 
in those forms of arthritis which go on to, an 
intense inflammation and even suppuration, what 
lesions do we find? An erosion and ulceration of 
tissues, a caries of bone, and finally a complete 
destruction and absorption of all surrounding parts. 
In myositis, as seen after wounds, the new for- 
mation is firm and fibrous in its nature, forming, 
as Billroth expresses it, an " inscriptio tendinea." 
In his opinion the process never goes beyond the 
formation of tendinous tissue ; but Weber and 
Gussenbauer maintain that a growth of muscular 
tissue gradually develops. At any rate the heal- 
ing process is complete, unless the inflammation 
has been so severe as to be suppurative. In such 
cases the muscular fasciculi undergo fatty degen- 
eration, and ultimately die. In this connection I 
would mention the comparatively rare condition 
known as fibroid induration of the heart. 1 This, 
in most cases, is a result of myocarditis, and is 
produced by inflammation of the peri- or endo- 
cardium, or in some cases by syphilis. It con- 
sists of the development of a fibrillated tissue 
between the muscular fasciculi, which is so pro- 

1 Green's Pathology, 3J Amer. Ed., p. 230. 



A PLEA FOR THE CURE OF RUPTURE. 39 

gressive in its growth that it causes atrophy and 
fatty degeneration of the muscles, and is one of 
the gravest of cardiac diseases. 

Finally, let us consider inflammations of the 
skin. No lesion which does not destroy the 
papillary layer produces a scar, or cicatrix. 1 When 
the papillary layer has been destroyed by ulceration, 
deep burns, scalds, or wounds, a firm contracting 
cicatrix is formed, " permanent, continuing to exist 
through life with but little alteration." 2 The fear- 
ful contortions produced by the contraction of 
scars from burns and scalds are an every-day 
occurrence, and require the utmost skill of the 
patient surgeon to overcome or even relieve. The 
same contortions are seen in injuries of deeper 
parts, as muscles, fasciee, and tendons. It is true 
these are all formed by a process of suppuration ; 
but the contraction is well marked, because there 
is no strain put upon the tissues to force them 
apart continually, as there is in the curing of a 
hernia. Indeed, treatment by mechanical exten- 
sion is one of the best methods of overcoming 
the deformity caused by a burn. 3 On the other 

1 Cornil and Ranvier, p. 734. 

2 Duliring: Diseases of the Skin, p. 54. 3 Bryant, Billroth. 



40 A PLEA FOR THE CURE OF RUPTURE. 

hand, it is a well-known fact that scars tend very 
gradually to become somewhat softened and oblit- 
erated, and, in accordance with the law I have 
deduced, that repair processes tend to reproduce 
the tissue of the region where they are seated ; 
that is, tend as regards the skin to develop grad- 
ually rudimentary papillae and epidermis. 

Since regenerated fibrous tissue tends strongly to 
contract, why is it that the operation of tenotomy 
relieves so much distortion and produces such good 
results ? Simply because the tendinous cicatrix, 
before it has fully organized, is more readily 
stretched than the original tendon of the muscle. 
" Tenotomy proves useful only from the orthopaedic 
after-treatment." When, therefore, suppuration 
unfortunately intervenes, the apparatus cannot be 
applied until the cicatrix is more firmly organized ; 
and, as a consequence, the benefit of the operation 
is far less. The same principle is true in the 
operation for strabismus. The muscle opposite to 
the one that has been divided rotates the eye so 
that the severe muscle shall gain a new attachment 
farther back. Therefore "it is better that the 
eyes should be moved about while re-union of the 
muscle is taking place, and especially that they 



A PLEA FOR THE CURE OF RUPTURE. 41 

should be turned in the opposite direction from 
that of the former squint : " x otherwise their condi- 
tion may be as bad as before the operation. 

My objects in thus discussing the various con- 
nective tissues of the body have been these : — 

1. To demonstrate that all fibrous tissues of the 
body tend, when inflamed, not only to contraction, 
but to a permanence of contraction. 

2. That it requires the greatest patience, to- 
gether with considerable mechanical skill, to over- 
come such permanent contractions when they have 
become fully organized. 

3. That while the inflammatory processes are in 
the course of organization, and have not developed 
into firm and stable normal tissue, they may, by 
the intervention of other processes, tend either to 
resolution or to suppuration ; both events resulting 
in destruction and absorption of inflammatory new 
growth either from a slow and imperfect healing, 
or from the antagonism of natural mechanical 
forces at work. 

4. That in no case have we seen any evidence 
of such resolution or absorption of inflammatory 
new growth when once it has become fully or- 

1 Williams: Diseases of the Eye, p. 327. 



42 A PLEA FOR THE CURE OF RUPTURE. 

ganized : therefore we must reason illogically when 
we make hernia an exception to the general rule. 

We have, then, seen the truth of the general 
law deduced by Billroth, and by Cornil and Ran- 
vier, that all processes of repair tend to reproduce 
the tissue of the region where they are situated ; 
that is, that these processes of repair are progres- 
sive in their nature until they attain a certain 
structure, which structure then becomes stable, as 
stable as normal tissue, and subject to the same 
laws of growth and decay. If a person has natu- 
rally weak abdominal fasciae, how can any one ex- 
pect a strengthening of one local portion to 
strengthen the whole abdominal area? In other 
words, it would be no unexpected event for a per- 
son to be permanently cured of an oblique inguinal 
hernia, and then to suffer afterward from a direct 
hernia. Is this an argument against the value of 
the method of subcutaneous injection? Yet many 
talk as if they thought it was. In other words, 
the return of a hernia once retained is not the 
only evidence that is essential. We must know, 
first, whether the fibrous tissue has ever seemed to 
be firmly organized, and, secondly, whether the new 
hernia is precisely in the same locality as the origi- 



A PLEA FOR THE CURE OF RUPTURE. 43 

nal lesion. I have seen several cases, and am cog- 
nizant of others where it was not. 

Clinical Experience. — We have lastly to con- 
sider the results of clinical experience. It is per- 
fectly in accordance with the wise conservatism of 
medical and surgical science, that, before an opera- 
tion shall become accepted and be admitted into 
general practice, it shall be able to produce as the 
result of a long and careful experience such a per- 
centage of complete recoveries as to render its 
adoption and approval by the profession an ad- 
vance in the progress of the healing art. The ob- 
jection has, however, been made to subcutaneous 
injection for the cure of hernia, that only a few 
trustworthy cures have been brought to the notice 
of medical men. That there might have been a 
valid objection to the operation before I took it up, 
I will not deny ; but certainly there has been some 
stimulus at work of recent years that has brought 
to the notice of the profession many trustworthy 
cases of the permanent cure of hernia by this 
method. It is now a number of years since I 
first operated for hernia by subcutaneous injection ; 
and I well remember that when, about four years 
ago, I read a paper upon the subject before the 



44 A PLEA FOR THE CURE OF RUPTURE. 

Suffolk District Medical Society, a worthy member 
thought two years of relief from the return of her- 
nia would insure the permanence of the cure. 
Fully that time has now gone by, and I have still 
been operating ; and, with few exceptions, I have 
not seen a case which, once pronounced cured, has 
had a return of hernia at the precise locality where 
I had operated. 

Nor do I stand alone in making such a statement. 
Many of my cases have been seen and thoroughly 
examined by my professional brethren both in this 
city and out of it, whilst the reports of other sur- 
geons in this country in regard to their success are 
as emphatic and conclusive as my own. We cer- 
tainly, then, are not at fault if successful cures are 
not yet known to the profession. Not only, how- 
ever, have I met with success in arousing the pro- 
fession to accept the operation as one of permanent 
value, but I have succeeded in proving it a safe 
procedure. Some of our best surgeons, who once 
considered it rather hazardous, have now emphati- 
cally said that the operation is free from danger. 
Nor is this all. There are few other operations 
that have presented, or that can present, such a list 
of favorable results in the practice of trustworthy 



A PLEA FOR THE CUKE OF RUPTURE. 45 

physicians. It is not necessary to quote cases 
taken from my own private practice. I trust it 
will be sufficient for me to say, that my own 
clinical experience, as well as that of other medi- 
cal gentlemen, fully support whatever may have 
been said in favor of this operation. 

Conclusion. — I have found, however, that there 
is an urgent necessity in the majority of cases for 
a more stimulating injecting fluid than the simple 
extract of oak-bark, and for an instrument which 
will more thoroughly and more effectually distrib- 
ute the fluid upon the hernial rings and canal. 
Nevertheless, I should think that, for children of 
the age of four or five, the simple extract, or the 
formula which, in my treatise, I have called For- 
mula A, amply sufficient. Upon infants and chil- 
dren under four years of age I still refuse to 
operate, because I consider the pressure of a good 
bandage or truss is better. There are surgeons, 
however, who operate upon infants in arms, and 
they report good results. 

I attribute my success in the operation mainly 
to three things, — 1st, The use of a stimulating 
mixture (Formula C). 2d, The use of an in- 
strument, the needle of which revolves and dis- 



46 



A PLEA FOE THE CURE OF RUPTURE. 



tributes the fluid more effectually than any instru- 
ment made under the pattern of a 
hypodermic syringe. (This instru- 
ment is finely made by George Tie- 
mann of New York.) 3d, The use 
of a truss as soon as possible after 
the operation. It is evident that an 
ordinary truss cannot be very early 
applied to the parts which are in a 
state of inflammation. For this rea- 
son I devised a truss, the pad of which 
is flat, and made of silver wire gauze. 
I call it the " Anatomical Truss." It 
tends to keep the rings together, rather 
than to force them apart, as every 
stuffed pad must do. External ap- 
plications can be made to the parts 
beneath if they become irritated or 
inflamed, and it is light and capable 
of such accurate adaptation to the 
tissues that it can be worn constantly 
with perfect comfort to the patient. 
I apply it eight or ten days after I have 
injected the hernial rings ; and the patient wears it 
night and day constantly for two or three months. 



A PLEA FOR THE CURE OF RUPTURE. 



47 



The truss is equally valuable for a patient who 
has had no operation performed, and will be found 
to give more relief than any padded truss. 

To show the value of this truss it will be neces- 
sary to give only a few characteristic cases from 
my clinical experience, which has been by no 
means limited in this direction. 




Mr. G., aged forty, with a large, direct hernia, 
was operated upon subcutaneously in the early 
part of the summer of 1881. Ten days after I 
injected him with my Formula C, I applied the 
anatomical truss, which he continued to wear 



48 A PLEA FOE THE CURE OF RUPTURE. 

night and day. The result was a perfect cure of 
the hernia, so that he was able to abandon the 
use of the truss from that time. While he was 
wearing the truss he met with two accidents, — 
one a fall down a flight of stairs, the other a 
violent strain while righting up a coal-cart. Not- 
withstanding all this the result was a perfect cure 
of the hernia, so that he was able to abandon 
the use of the truss after having worn it three 
months. 

Mr. C. McC. was operated on early in October, 
1881, for a double oblique inguinal hernia of ten 
years' duration. Eight days after the operation 
I applied this truss, which he wore for three 
months night and day. During this time he slipped 
on the ice, and was slightly re-ruptured on the side 
where the large hernia had been. He consulted 
me about the first of January. I found the new 
hernia to be a direct one. I ordered him to wear 
the truss, and in April found him cured on both 
sides. He wears the truss now for safety when- 
ever he is to undertake any heavy work requiring 
violent exertion. 

Dr. D. was operated upon in November, 1881. 
He was fifty-four years of age, and was ruptured 



A PLEA FOR THE CURE OF RUPTURE. 49 

on the left side when twenty months old by a nurse 
falling upon him while carrying him in her arms. 
The hernia was very large, the scrotum being filled 
and distended with intestine and omentum. All 
kinds of artificial supports had been applied without 
the least benefit. Finally, the parts became so 
irritable that no support could be endured. The 
doctor is a liberally educated, conservative gentle- 
man, and a surgeon of experience in the late Con- 
federate army. To give his evidence upon the 
value of the anatomical truss and operation, I 
quote from a letter written to me by him on May 
22, 1882. He says, "My general health has 
been excellent since I saw you, and I am per- 
suaded that the operation for hernia will prove an 
entire success. By strict observance of all your 
instructions, I have escaped all accidents, and feel 
as strong and sound in the region of the operation 
as I do upon the opposite side. I cannot imagine 
a case that could have progressed, more favorably 
or promised better results. I have frequently 
placed my fingers on the truss-pad during the act 
of coughing and sneezing, to receive the impulse 
of the viscera, but cannot detect that there is any 
more sensible movement communicated by the pad 



50 A PLEA FOR THE CUKE OP RUPTURE. 

than the general vibration felt over the entire 
abdominal wall. 

" It is difficult for one like myself, who has been 
so long impeded in his movements, and who so 
suddenly regains or rather acquires strength and 
a feeling of security . from danger, to restrain him- 
self from excesses ; and the effort to control my 
exuberant spirits is almost beyond my power of 
will." 

This was one of the most hopeless cases I ever 
operated on ; and had the patient not been a 
physician, who knew how to take care of himself, 
I should not have undertaken the treatment. 

To illustrate the well-known fact, that recent 
hernia may often be cured by wearing a truss 
persistently, even without any operation, I select 
the two following cases : — 

Mr. W., a builder, aged thirty- five, referred to 
me by Dr. W., had a direct hernia upon the right 
side, of about the size of a hen's egg. I, being 
sick at the time, postponed the operation for six 
weeks, advising him in the mean time to wear 
a truss. At the end of this time I found the rings 
so firmly united and occluded, from the wearing of 
this truss night and day, that no operation seemed 



A PLEA FOR THE CUKE OF RUPTURE. 51 

necessary. At the time of writing this, the patient 
seemed cured, without operation. 
, Mr. B., aged thirty, applied to me in December, 
1881, with a small hernia, caused by a violent fit of 
coughing. Being engaged with more formidable 
operations at that time, I deferred operation upon 
him for a few weeks, advising him meantime to 
wear a truss night and day. He neglected to pre- 
sent himself for operation until early in May, 1882, 
at which time I considered him entirely cured, and 
advised him to discontinue wearing a truss. 

These two latter cases, as I have said, illustrate 
the well-known fact that recent herniae can often 
be cured by persistently wearing a truss, even 
without any operation. If, then, hernia can be 
cured in its early stage by a properly adjusted pad, 
it is not surprising that old herniae can likewise be 
cured by a suitable pad if once the fibrous rings 
are freshened and stimulated into activity by this 
operation of injection. 

As it might be interesting to the reader to learn 
the result of my operations by the subcutaneous 
method, I submit a few in the following report. 1 

1 See end of chapter. There are also about forty cases from whom I have not 
heard. Presumably, therefore, they are cured, or they would have complained to 
me before now. 



52 A PLEA FOR THE CUKE OF RUPTURE. 

It will be seen that in this report of cases none 
are included that have not stood the test of two 
years of time since the operation, as I wish to apply 
a test of this length of time before reporting any 
of my cases cured, although I have operated on 
many since 1881 that to all appearance are perma- 
nently cured of their ruptures. Still I do not wish 
to report them until sufficient time has elapsed, 
that we may feel each case is permanently and 
soundly cured, and most thoroughly tested. In 
addition to these twenty- eight cases I should men- 
tion that I operated on two others not included in 
this report, that were not benefited except so far as 
a slight contraction of the rings made the reten- 
tion of the hernial protrusion easier, and the wear- 
ing of a truss more comfortable. One, I feel 
confident, would be cured by one or more injec- 
tions ; the other I could not expect to cure, as it 
was a very large direct inguinal congenital rupture, 
and both rings were melted into one another. The 
operation was undertaken as an experiment from 
the first, as no expectation of a cure could be held 
out to the patient, and the person understood it ; 
but he was anxious to try the operation. In none 
of these cases excepting one, was a second opera- 



A PLEA FOR THE CURE OF RUPTURE. 53 

tion performed. In this one case the tissues over 
the hernia slightly protruded, but this protrusion 
was overcome by the second injection. 

Synopsis of Subcutaneous Operation. — In view of 
the interest which has been shown in the method 
for the cure of hernia by injection, and owing 
to the fact that comparatively few are familiar 
with the method and its application, I have pre- 
pared the following brief outline of the method, 
thinking that it might be of value to the readers 
of this paper : — 

This operation is no longer an experimental one, 
nor of doubtful expediency, but has been fully es- 
tablished as safe and expedient. Much of the suc- 
cess of the operation, however, depends upon the 
judgment of the operator, as shown in the selec- 
tion of cases and in the after-treatment. The in- 
jection will cure cases of all ages ; but the most 
favorable age is from four to twenty-one years. 
Before the age of four I do not think it expedient 
to operate. After twenty-one, more care is required 
to obtain good results ; but the best results are 
often obtained in those of advanced age. Sex 
seems to have no influence for good or bad. Oc- 
cupation may have an after-result in reproducing 



54 A PLEA FOR THE CURE OF RUPTURE. 

hernia at the same place as the first, if too great a 
strain is brought upon the place too soon after the 
operation, or near it where the first hernia is re- 
tained, a direct rupture occurring through weakened 
abdominal walls. 

As in all operations, the success is greatest, 
other things being equal, in those of a healthy 
state. Constitutional disease, however caused, re- 
tards the process of cure, and may prevent it. In 
such cases tonics (as quinine or iron), to counter- 
act the general debility, and specific remedies 
(mercury, iodides, etc.), to counteract the specific 
diseases, are indicated ; the operation being delayed 
until the system is built up. 

Nervousness is to be considered on account of 
the time that is to be spent in bed on the back ; 
and the nervous system, if highly excitable, should 
be toned down by appropriate remedies. An irri- 
table spine is unfavorable to the operation. 

The kinds of hernia enumerated in the order of 
the best results and least danger are inguinal, um- 
bilical, and femoral. Large congenital herniee in 
persons over forty are very unsatisfactory, as the 
two rings are practically fused into one, and there 
is no canal left for the injection to act on. 



A PLEA FOR THE CURE OF RUPTURE. 55 

The hernia must he reduced. Hernias appar- 
ently irreducible may often be reduced by patient 
trials. Taxis is to be aided by position, by ether, 
by ice-poultices, and by subcutaneous injections of 
sulphate of morphia and sulphate of atropia, com- 
bined or separately. Adhesions may be broken by 
manipulation or by subcutaneous division, or the 
tumor may be gradually reduced by an elastic cup- 
truss. 

The hernia being reduced, the middle finger of 
the left hand is carried up into the opening of the 
external ring, the scrotum being invaginated. 
The reduced intestine is held back by this finger. 
The tip of the index finger, placed in its natural 
position by the side of the middle finger, points to 
the site of the puncture for the needle of the 
syringe. This puncture is opposite the external 
ring. It is- not made through the scrotum, but 
through the skin of the abdomen in the inguinal 
region. The needle is passed carefully into the 
canal, avoiding the cord and the vessels. It is 
evident that the operator must be a good anatomist 
and a skilled surgeon. The finger being in posi- 
tion, the fluid is forcibly injected along the tract of 
the canal, — not into the sac, nor into the peritoneal 



66 A PLEA FOR THE CURE OF RUPTURE. 

cavity. The fluid is still injected as the needle is 
withdrawn ; and at the same time the needle is 
revolved so that every part of the canal shall be 
bathed with fluid. The syringe which I have de- 
vised for my own use does this automatically ; for, 
on opening the valve by pressing the lever, the 
spring on the piston-rod forces out the fluid through 
the holes in the sides of the needle, which is at the 
same time rotated by the act of withdrawal, owing 
to its twisted form. I do not say that this instru- 
ment is necessary for a perfect result ; but it makes 
the operation easier, and simplifies the injection, so 
that the result is more likely to be favorable. The 
common hypodermic syringe will not answer ; for it 
delivers the fluid against the sac, and not on the 
walls of the canal ; and the scarf-point is danger- 
ous, as arteries may be wounded by it. An instru- 
ment which delivers the fluid x only in drops is not 
of as much value as one that sprays the fluid forci- 
bly upon the tissues. 

When the injection has been made, the ring will 
be felt to contract like a sphincter round the tip 
of the finger, and from my experience I do not 
expect a favorable result unless I feel this contrac- 
tion. When the needle is withdrawn, the finger is 



A PLEA FOR THE CURE OF RUPTURE. 57 

to be placed over the puncture to prevent the 
escape of fluid. 

This is also guarded against by making the 
puncture with the skin drawn tense, and thus 
making a valve-like puncture. 

The amount of fluid varies with the size of the 
hernia and the irritability of the tissues. The larger 
the hernia and the older the patient, the more 
stimulating should be the fluid, and the greater 
the amount injected. Inguinal hernias require the 
greatest amount, while femoral require the least, — 
about one-half as much as inguinal. 

The fluid that I use is made according to one of 
the three following formulas : — 

Formula A. — For infants and children, whether 
the hernia be accidental or congenital. 

]$ Fl. ext. Qnercus albse . . . . §ij 

Reduced by distillation to |j 

Alcohol, 90 per cent .... 3ij 

Ether sulph. ..... 3j 

Morph. sulph. ..... gr. ss. 

M. Sig. Inject 8-10 minims. 

Formula B. — For old and long-standing hernia?, 
whether congenital or acquired. 

IJ Fl. ext. Quercus albse . . . ^iv 

Reduced by distillation to . . §j 



5" 

§ss 

3ii 
gr. iv 

3ii 



58 A PLEA FOR THE CURE OF RUPTURE. 

Alcohol, 90 per cent .... 3iij 

Ether sulph. . . . . . 3ij 

Morph. sulph. . . . . . gr. ij 

M. Sig. Inject 10-25 minims. 

Formula C. — Best in the majority of cases. 
]J Fl. ext. Quercus albse . . . . jvj 
Reduced b} T distillation to 
Alcohol, 90 per cent . 
Ether sulph. .... 
Morph. sulph. .... 
Tine, veratri viridis 
■M. Sig. Inject 15-20 minims in small and recent hernise, 
but 25-50 minims in large or old herniae. 

Note. — This fluid will cause a marked reduction of pulse and 
temperature, and it may be necessary to put a hot-water bottle to the 
patient's feet. This reduction may last as long as fortj'-eight hours, 
and gives a decided advantage in obtaining a more decided local effect 
of the irritant. 

By this combination I think that the best results 
will be obtained. Other remedies have been used, 
as iodine, ether, alcohol, sulphate of zinc, etc. 
The object of any fluid that is used is to cause irri- 
tation, and set up effusion. Carbolic acid and simi- 
lar fluids will not effect this, and consequently are 
not of use. 

The injection is performed with the patient lying 
in bed on his back, and, being completed, a com- 



A PLEA FOR THE CURE OF RUPTURE. 59 

press and spica bandage is applied. Pain and 
restlessness are to be subdued by sulphate of mor- 
phia, and a compress of cold water may be placed 
over the site of the operation if the pain is intense. 
Quiet and maintenance of the position on the back 
are to be insisted upon ; but if the patient, for some 
urgent reason, turns upon his side, or is restless 
within the twenty-four hours following the opera- 
tion, the success of the operation is not of necessity 
destroyed, although it is endangered. The bowels 
are to be moved just before the operation, and not 
again for several days. The urine may have to be 
drawn ; but this is the exception. Light food is to 
be given, and quiet maintained. 

The slight fever that follows does not need medi- 
cation as a rule. The injection is to be aided by 
rest and position, and by the pressure of a spica 
bandage. In eight or ten days, if every thing has 
gone well, the patient may stand up, the operator 
supporting the parts with the hand ; and, if the 
opening is felt to be occluded, we may fit a light 
truss, and let the patient go, cautioning him to favor 
himself for a short time. In a few months another 
examination is to be made ; and, if all is well, the 
truss may be dispensed with. 



60 A PLEA FOR THE CURE OF RUPTURE. 

If, during the treatment, an abscess forms, it is 
to be treated according to the rule, being opened 
antiseptically, and constitutional symptoms met as 
they arise. An abscess should not occur, and 
shows that there has been an error in judgment, 
either in selecting the case, or in using too much 
or too stimulating a fluid. Every swelling is not 
an abscess. A swelling simulating an abscess may 
appear a few days after the operation ; but in reality 
this is only effused lymph. This will be dis- 
colored by the injection, and look as if there was 
decomposing blood in it. A few days will decide 
whether this is an abscess or not, as it will either 
be absorbed, or else will " point." 

As a final result we may confidently expect a 
cure. In extreme cases more than one injection 
may be necessary. In no case is the operation 
dangerous any more than hypodermic medication 
is dangerous ; and, if it is not fully successful, it 
will at least better the state of the patient, inasmuch 
as it will contract the rings in a degree, and tend 
to retain the hernia by as much as the rings are 
contracted. 

The object of the operation is not to set up in- 
flammation in the sac, nor to cause peritonitis, 



A PLEA FOR THE CURE OF RUPTURE. 61 

nor to set up an imaginative tendinous irritation. 
Neither does it avoid inflammation altogether. On 
the other hand, it aims to set up inflammation of a 
mild type in the fibrous tissues of the hernial canal 
and its rings. 



62 A PLEA FOR THE CURE OP RUPTURE. 



PART III. 

HISTORY OF MY CONNECTION WITH THE 
METHOD OF SUBCUTANEOUS INJEC- 
TION FOR HERNIA. 



The following and some of the preceding papers 
which I read before the American Medical Associa- 
tion at Cleveland, O., June 7, 1883, were very gen- 
erally and profitably discussed. Dr. William Byrd 
of Quincy, 111., President of the Surgical Section 
last year, had operated five times with success, 
using Warren's instrument and Formula C. He 
thought very highly of the method when it was 
properly performed in accordance with the author's 
directions. Dr. Murray of Indiana had operated 
three times successfully, and wished to express his 
personal thanks to the reader for his paper, and 
thought the association and the profession at large 
should feel grateful for the thorough manner in 



A PLEA FOR THE CURE OF RUPTURE. 63 

which he had broaght the matter to scientific 
notice. The safety and great benefits of the sub- 
cutaneous operation have thus, by the author's 
labors, been fully demonstrated ; and the profession 
is daily recognizing and accepting it. Many other 
gentlemen testified to a personal and satisfactory 
experience with the operation. 

To the question why the veratrum viride was 
used in my formula, I replied that by it a great 
reduction in the rapidity of the heart was obtained, 
the pulse sometimes falling to fifteen or twenty 
beats per minute. This reduction of the circula- 
tion enables us to bridge over the first forty-eight 
hours after the operation, so that there is less fear 
of a general inflammatory action. Thus, too, more 
of the irritant fluid can be injected, and a greater 
amount of local inflammation set up in the hernial 
rings, than would be possible with the simple 
extract of oak-bark. 

Dr. Hallen of Kansas City spoke of two cases 
of abscess occurring after using, as he thought, the 
author's Formula C. This could not have been 
possible in his cases ; for, at the time of the opera- 
tions, the formula had not been published. But, 
even if he had used this formula, it would not have 



64 A PLEA FOR THE CURE OF RUPTURE. 

been strange if abscesses had resulted, because it 
is a very difficult fluid to prepare properly ; and it 
is quite possible that in his fluid there might have 
been some impurity or foreign substance. Then, 
again, the instrument he used might not have been 
a proper one, or not thoroughly cleaned. We all 
know that from the simple injection of morphine, 
or from a vaccination, abscesses sometimes result ; 
and yet this does not deter us from making use of 
these procedures when they are necessary. At 
any rate, the number of abscesses resulting from 
the two thousand operations of subcutaneous in- 
jections for hernia that I believe to have been 
performed have been remarkably few. 

I have said the fluid I use is a very difficult one 
to prepare. For the benefit, therefore, of those 
wishing to prepare a satisfactory fluid, I take great 
pleasure in inserting here Mr. Richard H. Kim- 
ball's method of preparing it for me : — 

FLUID EXTRACT OF OAK-BARK FOR PREPARING DR. 
WARREN'S INJECTION FLUID. 

Take of oak-bark in No. 50 powder 16 troy ounces ; moisten 
with a mixture composed of glycerine 2 fl. ounces, alcohol, 
aqua aa 7 ounces. Pack firmly in conical glass percolator, 
and add gradually of the mixture of glycerine, alcohol, and 
aqme, until all has been added. Then add a mixture of 



A PLEA FOR THE CURE OF RUPTURE. 65 

alcohol and aqua (equal parts) until it begins to drop from 
the percolator ; then close the orifice with a cork, and macer- 
ate four daj's. Remove the cork, and continue percolation 
with a mixture of alcohol (3 parts), aqua (5 parts), until 14 
fluid ounces have passed. Set this aside, and continue per- 
colation until exhausted, adding a small portion at a time 
of a mixture in which the quantity of alcohol is diminished 
from that used in each preceding addition. Evaporate this 
product very carefully on a water-bath to the measure of 
2 fluid ounces, and add to reserved 14 fluid ounces. Then 
continue the evaporation until the amount is reduced to 6 
fluid ounces. 

DIRECTIONS FOR PREPARING DR. WARREN'S FORMULA 
C FOR INJECTION IN HERNIA. 

R Fl. ext. oak-bark (Kimball's Formula) § ii 

Alcohol, 90 per cent ^ ss 

Ether sulph. cone. 

Tr. Veratri viridis aa 3 ii 

Morph. sulph gr. iy 

M. 

First place the extract of oak-bark in a suitable bottle ; 
dissolve the morph. sulph. in the tr. Verat. virid. ; shake 
well for a few minutes, then mix with the alcohol and ether; 
gradually add this mixture to that of the oak-bark, and 
shake. Place in an ounce-bottle securely corked, and pro- 
tected from the light. 

In the other formula the morph. sulph. should be dissolved 
in a few drops of distilled water, and added to extract of 
oak- bark ; and the other articles in the same way as in 
Formula C. 



66 A PLEA FOR THE CUKE OF RUPTURE. 

The following is from my Address before the 
Surgical Section of American Medical Association 
at Cleveland, O. : — 

In order that the profession may more fully 
appreciate my labors in developing the operation 
of subcutaneous injection for hernia, I feel that 
the time has come. to relate to them in the fullest 
manner my earliest connection with the whole 
matter. Years ago, when this association failed in 
obtaining the secret of the operation from Dr. 
George Heaton, I was conversant, as were some 
of you also, with the fact that he had cured many 
of our patients of hernia in some mysterious 
manner. Later in life, Dr. Heaton employed me 
as physician in his family, and still later for 
himself. 

In the acquaintance which then ripened into 
friendship, I once asked- him what good he had 
ever done in his life for the profession of which he 
was a member. Musing a few moments he said, 
" Have I not cured thousands of cases of rupture?" 
— "Yes," I said, " we will concede this to be true : 
but it has been done, sir, in a selfish way, as I look 
upon it ; and I cannot see that you have done any 
thing to elevate your profession." To this he said, 



A PLEA FOR THE CURE OF RUPTURE. 67 

"What would you have me do?" I answered, 
" Make public the secret you have hugged and 
guarded so faithfully for years." But said he, 
" You know all about it. I have shown you how 
to perform it. You may publish it, and I will fur- 
nish you with reports of cases," etc. 

I, however, recommended a younger man for the 
work ; and he soon, upon my approval, secured 
Dr. Davenport for an editor. But after the publi- 
cation of the book, he came to me in great lament, 
lest some one who did not practically understand 
the operation should attempt it, and fail. Indeed, 
a case had been operated upon without success in 
one of our hospitals ; and said the doctor, " They 
cannot, without personal instruction, properly com- 
prehend just what I do. Besides injecting the 
rings," said he, " you know that I am in the habit 
of rubbing and kneading the parts with my fingers 
to get up irritation sufficient to bring about adhe- 
sions. But, if one simply reads my book, he will 
think he understands the operation, and then will 
fail in his attempts to do it, and blame me for false 
pretensions. I reasoned with him, and told him, 
among other things, that his idea of the pathology 
of the operation was wrong, and that some de- 



68 A PLEA FOR THE CURE OF RUPTURE. 

gree of inflammation must certainly be excited in 
order to obtain adhesions. Finally he decided to 
produce another edition of his book, with fuller 
explanations in it ; - but Dr. Davenport did not 
appreciate his wishes, and, indeed, soon after died : 
so that Dr. Heaton never published a second edi- 
tion of his little book. 

As patient after patient began to come to me, 
after Dr. Heaton's death, to show me that they had 
certainly been cured of rupture, and to beg that 
I would not let the operation fall into disuse, 
I could entertain, in return for such praise, and 
regard for me, nothing but the tenderest feelings. 
Although I had at that time some doubts of the 
entire safety and propriety of the operation, which 
doubts I confided to a few of my professional friends, 
the enthusiasm of the patients was so spontaneous 
and entirely unexpected, that I resolved to do what 
I could to maintain their high esteem for me, and 
attempt to develop the operation to the best of my 
ability. 

In my desire to be minute in this sketch of my 
connection with the operation, I trust I do not 
seem too egotistical; but I am earnest to have it 
thoroughly understood that I was led to develop 



A PLEA FOR THE CUKE OF RUPTURE. 69 

the operation, not because of selfish greed, but 
because of the number of patients who begged me 
to do something for them in their distress. I did 
not assume the operation ; but it was thrust upon 
me in a most inexplicable manner. Long did I 
hesitate before accepting the extra responsibilty ; 
but, on the other hand, I knew that if I did not 
take up the burden, it would be sure either to die, 
or else fall into the hands of unscrupulous and 
irregular practitioners. 

Thanks to my many friends, especially the ed- 
itors of home and foreign medical journals, I have 
already accomplished far more than in my highest 
ambition I ever dreamed of doing ; and yet, al- 
though I have freely given to the profession all the 
results of my labors in the matter, I do not allow 
myself to think for a moment that I have ceased to 
improve the methods of curing hernia. Every day 
I am learning new features in the successful treat- 
ment of the disease, and I shall as freely give all to 
the profession in the future as I have in the past. 

And yet I have not been free from the seductive 
inducements of those who would prey upon a suf- 
fering humanity. Among others, I will mention 
the offer that one physician (and he an editor of a 



70 A PLEA FOR THE CURE OF RUPTURE. 

medical journal) made to me. He said lie was 
supported by medical men who authorized him to 
offer me twenty-five thousand dollars per year, with 
a hospital at my disposal of whatever description 
I would mention, if I would go to a large city he 
named, and operate for hernia. Another came, 
authorized to pay me any sum I chose to demand, 
if I would allow my method to be advertised in 
the daily papers. So greatly did these importunate 
offers annoy me, that I wrote the following letter 
to my friend, Dr. J. Collins Warren, editor of 
" Boston Medical and Surgical Journal : " — 

51 Union Park, Boston, Sept. 29, 1879. 

Mr. Editor, — Will you please to insert this note 
in your valuable journal, for the information of numer- 
ous inquirers, and greatly oblige me? 

Many letters are being addressed to me, inquiring 
about the new instrument and my method of operat- 
ing for radical cure of hernia. 

I would say that the instrument which I showed at 
the last meeting was made for me after my device and 
invention, and it does its required work very well ; but 
I am now having another instrument made, which will 
be finer in ever} respect, and much more perfect, and 
will do the operation perfectly with greater certainty 
of success. 



A PLEA FOR THE CURE OF RUPTURE. 71 

At our next meeting I hope to show this new instru- 
ment as fully perfected, and also describe my method 
of performing the operation. 

I would add, that, although the operation is com- 
paratively painless as I perform it, yet a marked in- 
flammation sets in about the parts, attended with some 
considerable swelling, in the course of from six to 
ten hours after the injection of the rings. This, with 
some fever and constitutional disturbances, continues 
for from three to six days, when it gradually sub- 
sides, leaving the rings occluded from the exudation 
which follows the inflammation set up by the injection. 

Unless this state above mentioned ensues, the opera- 
tion will be of no benefit in contracting and closing the 
hernial rings. 

By exciting as little inflammation as possible, as has 
been done heretofore, we get, it is true, some adhesion 
of the rings ; and the hernia is retained for a longer or 
shorter time. But, from the fact that very delicate 
adhesions are formed from the slight inflammation and 
exudation, the hernia will most likely be retained for 
only a short time. 

The exact amount of the injection mixture required 
must depend on the good judgment of the operator in 
each case. If the hernia is of long standing, and there- 
fore large, it will of course take more than in recent 
cases, and those of small size. 

It is my intention, as soon as I can obtain the time, 



72 A PLEA FOR THE CUKE OF RUPTURE. 

to give to the regular profession a detailed description 
of the operation, its method and results, in a legitimate 
way, and one which will, I trust, be acceptable to all. 

I will add for all concerned, that all offers of part- 
nerships, money, and hospitals, that are now made me, 
and that may be hereafter offered, in any other than a 
regular and professional manner, will be rejected with 
that same contempt that I have always looked upon 
them. 

I intend that this operation shall be given to the 
profession which 1 love ; and I am certain that on full 
investigation it will receive the merit which it deserves. 

I will further add, that, when I think proper, I shall 
establish a private hospital on my own account, and 
of this the regular profession will be informed. 

Mr. Editor, I would not have detained you so long, 
but I wished once for all to reply to the contempti- 
ble offers and overtures which are made to me ; and 
that I also wished to express my delight at the interest 
which is shown by the regular profession. 

As soon as my instrument is completed, I will give 
notice at what places it can be obtained. 

I have the honor to be 

Yours respectfully, 

JOS. H. WARREN. M.D. 

Per'C. E. W. 
For The Boston Medical and Surgical Journal. 



A PLEA FOE THE CURE OF RUPTURE. 73 

Dr. Warren, thinking the matter too personal, 
was unwilling to publish it at that time. I agreed 
with him in his decision ; but I wrote it under great 
pressure, and with the feeling that I needed pro- 
fessional support and sympathy. Not only did I 
fear that the operation would fall into unworthy 
hands, but I saw with astonishment that some of 
the regular profession were inclined to give sup- 
port, not to me, but to the pretensions of a man 
who had learned from me all that he ever knew 
of this operation. 

In my desire for sympathy, I now sought my old 
and highly esteemed friend, Freeman J. Bumstead, 
M.D., president of Kings County Medical Society, 
New York. He had investigated the operation, 
and had conferred with Dr. Heaton in regard to 
a hernia upon the right side, from which he him- 
self was suffering. He advised me to publish my 
method in all the medical journals, and then, as 
soon as possible, to produce a book upon the sub- 
ject. " It must be made common property to the 
profession, or else," said he, " the irregulars will 
seize upon it, and take it from the hands of the 
legitimate practitioners." So it will be seen that 
even this duty of presenting myself so often in the 



74 A PLEA FOR THE CUEE OF RUPTURE. 

medical journals was not of my own choosing, but 
was in a manner imposed upon me. 

And yet no one so well knows the many defects 
and imperfections in my writings as I myself know 
them. In part excuse for this, I have to offer my 
busy life as a general practitioner ; for I have never 
devoted myself to this operation as to a specialty, 
nor have I expected to reap my greatest reward in 
or by financial profits. But yet — for I am neither 
rich nor poor in earthly goods — I thank my breth- 
ren in the profession for the many patients they 
have referred to me, and assure them that I re- 
member their courtesy, friendship, and good feel- 
ings toward me. My greatest reward shall be that 
I have given and shall continue to give the results 
of my best endeavors freely to the profession ; for 
in loyalty and faithfulness to the advance of our 
profession I allow no one to exceed me. 

Having now, for the first time, fully related the 
history of my connection with this operation, I 
deem it necessary to offer a few friendly words of 
criticism upon the methods in which it is usually 
performed by the profession at large. The subcu- 
taneous injection for hernia cannot be a successful 
operation until it is fully understood that something 



A PLEA FOR THE CURE OF RUPTURE. 75 

more is to be done than merely to inject the her- 
nial rings with a little of the simple extract of 
oak-bark, to apply a bandage, and, after a few 
days' rest, turn the patient over to his own care, 
thinking that a miraculous cure has been effected. 
For a few days or months the parts may. it is true, 
hold together after such an operation ; but it will 
be only by the merest accident that this sham pro- 
cedure will accomplish a permanent result. 

In all my professional experience of over thirty 
years, I am free to say that I have never performed 
an operation that requires such constant care, pains, 
and patience, as this. The injection itself requires 
skill and care, and then the patient must be kept 
quiet in bed until the fibrous tissue shall have had 
time to become consolidated. I would here make 
mention of a very useful pin 1 for the application of 
the proper bandages for the operation. It is the 
invention of my son, Dr. C. Everett Warren. 

Many operators seem to think, that, because the 
method seems simple, it can therefore be done in 
the most routine manner, and that, if patients are 
made to understand that the operation is not so 
simple a matter for the surgeon, as many would 
have them believe, they will refuse to be operated 

1 See illustration, p. 111. 



76 A PLEA FOR THE CURE OF RUPTURE. 

upon, and so will force the method into disuse. 
This is not so : rather will sufferers from rupture 
refuse to be operated upon, if they see careless 
operators fail in operations where more painstaking 
and prudent men would possibly succeed. 

I do not wish it understood that I am fault- 
finding or egotistical when I say that those who 
have used my instrument and my Formula C have 
been more successful than all other operators who 
have worked in their own ways. I do not intend 
to. set myself up as the only authority in this opera- 
tion; but I must maintain, that, if my success in 
curing cases of rupture is greater than the success 
of others, as it certainly has been, there must be 
a competent cause both for my successes and for 
their failures. 

I fear that too often the surgeon does not take 
care, at the time of operation, to feel the rings and 
surrounding parts contract upon the end of his finger 
while it is in position ; and many a time it would seem 
that he has no very definite idea where the fluid has 
been deposited. Too often it is thrown into the pillars- 
and surrounding tissues, and not into the rings them- 
selves, especially into the inner ring. Again, it must 
rest with the good judgment of the operator to 



A PLEA FOR THE CUKE OF RUPTURE. 77 

determine the proper amount of inflammation to 
excite. 

Such is my faith in this operation, that I consider 
it only in its earliest infancy. So much have I 
learned from my experience with it, and so much 
has it developed in my hands, that my operations 
now are far more thoroughly performed, and are 
more successful, than were my earlier ones. I know 
just how much to expect from it, and can therefore 
judge what cases will be most benefited by its use ; 
for, in order to be successful, we must use rare 
judgment in this operation, as in all others, and 
select our cases properly. Whatever doubts and 
prejudices I formerly entertained in regard to the 
excellent and undoubted results of the method of 
subcutaneous injection for hernia have long ago 
disappeared ; and I feel confident that yours will 
likewise disappear, if you study the subject in a 
careful and unprejudiced manner. 

Yet there are those, I must confess, who still 
pretend to be sceptical of the permanent success 
that we know we do obtain, and who maintain that 
this operation, like others that have preceded it, 
will fall into neglect and disuse. Such will not be 
its fate, if I am able to judge any thing of it by my 



78 A PLEA FOR THE CURE OF RUPTURE. 

experience; for it is daily gaming strength, and 
patients are so well pleased with it, that I am, per- 
force, led to hope that soon hernia? of long stand- 
ing will be a thing of the past. In all cases the 
sooner an operation is performed after a hernia 
has occurred, the better; and this is only the same 
principle that is now applied by the best medical 
men to the treatment of stone in the bladder, or of 
ovarian tumors. 

But even then we cannot always promise a cure ; 
for I suppose there is no operation in which we 
require so much the hearty co-operation of our 
patient, and his implicit obedience to our instruc- 
tions, as this. Too often a successful operation is 
rendered a failure by the future life and habits of 
the patient, acting contrary to our commands. In 
conclusion, I recommend for your first patients 
those who have small and recent hernise, and who 
are themselves young and healthy. 

A few words as to the future of this operation. 
With the best wishes for success to every one who 
shall be encouraged to try this subcutaneous 
method, I thank this association for granting me 
the privilege of explaining my relations to the 
operation, and trust that it will never be allowed 
to fall into the hands of irregular practitioners. I 



A PLEA FOR THE CURE OE RUPTURE. 79 

have succeeded, thus far, in curing fully ninety per 
cent of all those upon whom I have operated ; but 
all must bear in mind that I have made a most 
careful selection of cases to be operated upon. 

If all hernia? that present themselves are oper- 
ated upon without discrimination, this average of 
successes will probably not exceed fifty-five or 
sixty per cent. But, even with such a propor- 
tion before us, we should not be justified with 
our present knowledge in refusing to operate 
upon cases that offer us even the least hope of 
success. Even if we do not succeed in closing up 
the rings, we shall at least contract them, so that 
the bowel can be more easily retained by a suitable 
truss. At any rate we shall do the patient no harm. 

I am now engaged in some experiments looking 
to a development of this operation that shall place 
it beyond all doubt of cavil as the very best that 
has ever been offered to the profession. If all 
works well, I hope to be able to place the results 
before the profession in the early months of 1884. 
Then, if my efforts to advance the progress of sur- 
gery, as applied to the relief of hernia, shall con- 
tinue to be appreciated as fully as they already are, 
I shall be amply repaid for all my great outlay of 
time and money. 



80 A PLEA FOR THE CURE OF RUPTURE. 



PAET IV. 

A PLEA FOR OPERATIVE MEASURES FOR THE 
RELIEF AND CURE OF HERNIA. 1 



The history of the last decade of medical and 
surgical art is everywhere pregnant with new ideas. 
Notable advance has been made in nearly every 
branch of abdominal surgery ; for, although the 
operations of gastrotomy, gastrostomy, laparotomy, 
enterotomy, colotomy, nephrotomy, and lithotomy, 
are not new in surgical annals, yet so much has 
been lately done to perfect these procedures, that 
they are now scarcely to be recognized as the same 
operations that we used to know. I say nothing of 
lithotrity, because the operation does not involve 
abdominal section ; and yet it comes so nearly 
within the circle of abdominal surgery, that not 
to mention it is to neglect that branch of surgery 
in which we can note the most advance. 

None of these operations, however, is for the 

1 Read before British Medical Association, Aus. 1, 1S83. 



A TLEA FOR THE CURE OF RUPTURE. 81 

relief of an affection more distressing or more dan- 
gerous than a hernia ; and yet the present age has 
not been active as it ought in devising means for 
the relief and cure of this complaint. The danger, 
pain, and mortality from hernia in all ages, sexes, 
conditions, and walks of life has far exceeded 
that from stone in the bladder ; and yet mark the 
difference in the advance of operative procedures! 
While various operations have been proposed for 
the relief of hernia, little was accomplished, up to 
Sir Astley Cooper's time, that was really tangible 
and acceptable. 

Moreover, as soon as a truss was found that would 
retain the rupture, it would seem that the profession 
gave their tacit consent to be directed in their efforts 
by the instrument-makers. This was practically 
the condition of affairs until Mr. John Wood pro- 
posed an operation, now honored by his name, 
although at first very coldly received by the pro- 
fession. And it was many years before other sur- 
geons thought it worthy of their imitation, although 
it had been a very successful procedure in Mr. 
Wood's hands, as he informed me in 1880. May 
honor be given to him for his patience and persist- 
ence in waiting and working until the profession 



82 A PLEA FOR THE CURE OF RUPTURE. 

would give him hearing and recognition in his 
operation ! 

Besides Wood, we might mention the names of 
Pancoast and Dowell ; but their many trials to gain 
a hearing before the profession were likewise un- 
heeded, and their many successful operations upon 
hernia have been well-nigh forgotten. Agnew, 
too, after attempting a modification of an old 
European operation with a complicated instrument, 
seems to have abandoned hopes of its success, and, 
unless he is incorrectly reported, is said to be un- 
able to see any need of any operation so long as a 
truss can be procured to sustain the rupture. In 
the great body of the profession, however, there has 
been within the last two or three years a renewed 
activity to discover some remedial means which 
shall succeed in permanently restoring the ruptured 
parts to their normal condition. At present, too, 
the prospect of success in this search seems to be 
more encouraging, more particularly because the 
profession is losing its distrust in the suggestions 
that are made, and are more inclined than in for- 
mer years to give respectful hearing to the claims 
of new procedures. 

Indeed, when we consider the danger there 



A PLEA FOR THE CURE OF RUPTURE. 83 

always is that a hernia once formed will become 
strangulated with possibly fatal results, I feel that 
we are warranted in assuming considerable risk, if 
need be, to afford some relief to the sufferer ; and I 
believe, with many others of the profession, that the 
time is not far distant when it will be considered 
that one who does not operate in some way for such 
cases has neglected his bounden duty to his patients, 
and must be held accountable therefor. " If, as a 
body of surgeons," said Dr. Freeman J. Bumstead 
once to me, ci we would only stop to consider how 
we should feel if we were obliged to wear a support 
or truss all our days, with the constant danger of 
fatality before us, we should be the very first to cry 
for some means of operative relief." 

In the very great majority of cases of hernia 
the method of subcutaneous injection affords com- 
plete and permanent relief: but occasionally we 
meet with large congenital and irritable herniae 
that can neither be retained by a truss, nor com- 
pletely cured by injections unless frequently re- 
peated ; and yet something must be done for their 
relief. Feeling, therefore, the responsibility that 
rests upon the profession, I take this opportunity to 
suggest a new method of procedure that promises 



84 A PLEA FOR THE CURE OF RUPTURE. 

most favorable results. Although somewhat similar 
to one proposed by Mr. Banks of Liverpool, yet in 
some features it differs materially and essentially 
from any that I have seen reported. 

My method is as follows : An incision is first 
made much the same as in the operation of ke- 
lotomy, except that it is longer. The superficial 
integuments are now retracted, and the rings ex- 
posed to view. The intestines being fully returned 
within the abdominal cavity, the old protruding sac 
is excised by the galvano cautery to a level with 
the pillars of the ring. The edges of this sac are 
now seized with serrated forceps in the hands of 
an assistant, care being taken not to bruise the 
edges. The operator now, with animal ligatures 
that have been thoroughly carbolized in oil, draws 
the two edges of this sac together by a continuous 
suture, leaving the ligatures long at both ends. 
The assistant holds the gut by these ligatures 
instead of by the forceps, while the surgeon thor- 
oughly freshens the pillars of the rings with the 
red-hot cautery. The pillars are next brought 
together, and the sac allowed to lie just beneath 
but in contact with them. 

A needle armed with silver wire is now passed 



A PLEA FOR THE CURE OF RUPTURE. 85 

deeply through the columns of the ring, and at the 
same time through the edges of the sac that we 
excised. This operation is repeated until sufficient 
sutures have been put in to draw the pillars well 
together. These sutures are then tightened either 
by twisting or by tying. The latter is the method 
that I prefer, because I can better judge the amount 
of tension, and am not so likely to produce a stran- 
gulation of the tissues. The ends of the carbol- 
ized ligatures are now cut off, the silver wire 
smoothed down so as not to cause irritation, and 
the external integuments stitched together with 
silver wire or silk. All that is needed to complete 
the operation is a compress of cotton treated either 
with thymol, boracic acid, or carbolic acid, and the 
application of a common spica bandage. 

The distinguishing features of this operation 
are the excision of the sac by the galvano cautery, 
the freshening of the edges of the rings by the 
same instrument, and the stitching of the sac and 
pillars of the rings together. By means of this 
freshening of the rings with the cautery, and the 
union of the sac to the pillars, an abundant exuda- 
tion of plastic material is thrown out, and a great 
increase in the strength and consolidation of the 



86 A PLEA FOR THE CURE OF RUPTURE. 

new tissue is produced, so that the results of the 
operation are rendered very permanent. The fol- 
lowing case will illustrate the success attending 
this method of procedure : — 

June 25, 1883, with the assistance of my son, 
C. Everett Warren, A.B., M.D., and William F. 
Temple, A.B., M.D., I operated as above described 
upon Mr. I. Welch, age 40, a builder by trade, who 
had been suffering about a year and a half with 
an enormous oblique inguinal hernia, filling and 
distending the scrotum to an immense size. The 
intestine could not be retained with the largest- 
sized pad of any truss. After cutting down and 
freely exposing the rings, I passed the galvano 
cautery around the parts at a red heat, completely 
denuding the pillars of the fascia, and brought the 
rings together with eight good-sized silver sutures, 
finally closing the rings in a manner similar to that 
reported by Mr. Banks in the proceedings at this 
meeting last year. The external tissues were re- 
placed and secured with six carbolized silk sutures, 
and a few strips of adhesive plaster ; a compress 
of absorbent cotton and a spica bandage complet- 
ing the dressing. But little suppuration followed. 
In the upper portion of the incision, to the extent 



A PLEA FOR THE CURE OF RUPTURE. 87 

of half an inch or more, there was free suppura- 
tion for seven or eight days, and a small drainage- 
tube was inserted. At the expiration of twelve 
days the parts were entirely healed, and the hernia 
was completely retained within the abdominal 
cavity. The patient goes about with the parts 
supported with a spica bandage and compress, he 
seems and feels sound, and is apparently cured of 
his distressing affection. 

I have made use of this method with the gal- 
vano cautery in three cases, all giving the most 
perfect results and satisfaction ; and I trust, upon 
further trial, that this method of operation will 
prove efficient in curing and relieving many cases 
of large and long-standing hernia. 

Considering the very satisfactory results which 
I have obtained in this mode of operating, I am 
led to highly recommend it to your most favorable 
consideration in many cases demanding operative 
measures ; and I think, that, in cases of strangu- 
lated hernia, when herniotomy is performed, the 
rings might be freshened by the galvano cautery 
to great advantage. 

As a duty to our patients, as well as affording a 
golden opportunity to ourselves as a profession 



88 A PLEA FOR THE CURE OF RUPTURE. 

burdened with responsibility in the application of 
our art in relieving and curing as far as possible 
all who may call upon us to relieve and assuage 
their sufferings, I trust all noble and well-minded 
of the profession who may read or hear this imper- 
fect paper will join the writer in this plea that 
something more may be accomplished for this 
large class of patients, suffering, and importuning 
us for aid in every civilized or uncivilized country 
in the world, and will alleviate this suffering by 
personal efforts and example, either by this 
method, or by suggesting something that shall 
be better. 

With the little danger attending surgical opera- 
tions, and particularly those of abdominal sections, 
as now practised, are we not warranted in our plea 
for something more to be done by operative meas- 
ures for the ruptured? I, for one, feel anxious that 
more of the better class of the profession should 
take hold of this very important branch of neg- 
lected surgery (neglected in the past at least) ; and 
I hope that those engaged in large hospital and 
private practice will turn their best experience and 
resources to accomplishing rich results in perfect- 
ing this operation for the relief of the ruptured as 
they have in perfecting other surgical operations. 



A PLEA FOR THE CURE OF RUPTURE. 89 

Should this paper by any means be a stimulus 
in calling attention to this subject, and arousing 
greater efforts in the matter under consideration, 
I shall feel that I have not made this plea in vain. 
May we not see in the near future something more 
in the text-books of surgery than the same old 
dull and unimportant recommendations of a truss 
to retain a rupture that persists in protruding, es- 
pecially as in many cases, with this imperfect 
appliance, strangulation occurs, which, if not re- 
lieved in season by taxis or herniotomy, ends in 
death ] These recommendations, and nothing 
more, have helped fill out the pages of every work 
on surgery, with a few commendable exceptions, 
for a hundred years or more, so copied and re- 
peated, that, if we read any of the old and well- 
known authors, we shall get all the essentials, at 
least, of a great portion of what the most mod- 
ern authors have to say, and shall be surprised 
to learn how little has been added by the recent 
writers on this subject. It is very strange indeed, 
to see how all decry and ridicule any way of re- 
lieving and curing the ruptured by any operative 
measure beyond wearing a truss ; and, more than 
this, not one in ten of the writers or practising 



90 A PLEA FOR THE CURE OF RUPTURE. 

medical gentlemen of to-day know how to tit a 
truss properly. They are not taught it in any 
of the hospitals or medical colleges ; but, with 
few exceptions, all refer their patients with rup- 
ture to the tender mercies of the tradesman or 
mechanical-instrument maker. Should we not, as 
a profession at large, be ashamed of so glaring 
a neglect of this most important duty] I my- 
self, and no doubt others, have seen patients 
who were fitted by these men, wearing trusses 
in such a ridiculous and laughable manner as 
to be in reality a cause of hernial protrusion of 
greater size than was the rupture in the begin- 
ning. I have been repeatedly informed by many 
a patient that a rupture, small at first, rapidly 
grew larger by the application of a truss im- 
properly fitted. Would any surgeon think of 
allowing the same class of men to fit a splint to 
a broken limb? and yet how much more impor- 
tant is a well-fitting truss to the comfort, safety, 
and life of our patients with rupture, than a splint 
to a fracture ! 



A PLEA FOR THE CUKE OF RUPTURE. 91 



PAET V. 

THE PROPER FITTING AND WEARING OF A 
TRUSS. 



The value of a truss may not be wholly to pre- 
vent an increase of a hernia already existing. It 
may also be curative in closing up the hernial rings 
if properly applied to the right case and in suffi- 
cient season. In any given case the surgeon's 
duties are twofold. He must in the first place 
select the proper truss, and then he must properly 
apply it, and give instructions for its use. Neither 
of these duties should be delegated to the instru- 
ment-maker, but should be done in person. 

A truss cannot bd manufactured upon abstract 
principles. It must be the result of careful ana- 
tomical study, and must be adapted to the age, sex, 
and condition of the patient who is to wear it. It 
must combine, moreover, lightness, strength, and 



92 A PLEA FOE THE CUKE OF RUPTURE. 



elasticity, so that it may be worn continuously and 
with comfort. A spring that is too feeble to retain 
the protruded intestines is a deception, for it gives 
to the patient the mere appearance of safety with- 
out any of the reality. On the other hand, a spring 
that is too stiff may do more harm than good by 
causing absorption of the abdominal parieties upon 
which it presses. 

Perhaps, however, the most important portion 
of the truss is the pad. Most of the trusses in 
common use are fitted with a hard and convex 
pad. This by its very hardness is uncomfortable 
to wear, while by its convexity it is tending con- 
stantly to stretch and weaken the intercolumnar 
fasciae, and thus to enlarge the hernial rings. The 
pad should never be of such a shape as to press in 
upon the tissues, or to invaginate them within the 
hernial canal. 

The most perfect support for a hernia is the 
human hand. Being slightly concave, it accurately 
fits the slight convexity of the abdomen at the 
groin. But the human hand is not available for 
this purpose : and the best substitute for it is a 
truss with a pad shaped as nearly as possible like 
the hand ; i.e., flat, but with a very slight concavity, 



A PLEA FOR THE CURE OF RUPTURE. 93 

which can be easily shaped by the surgeon to the 
particular abdomen under consideration. Such a 
support is my Anatomical Truss (see " Practical 
Treatise on Hernia," second edition, p. 321) now 
lately modified (see present book, p. 47). 

Having selected the truss proper for the given 
hernia under consideration, the surgeon must next 
use judgment in applying it. The pad must be of 
such a size as to overlap the hernial rings by half 
an inch on all sides, and should be so fixed to the 
spring as to" exert a pressure at right angles to 
the plane of the hernial aperture. Thus, in a 
subject with a large abdomen and an inguinal 
hernia, the pressure should be upward, or upward 
and inward ; while in thinner subjects it should be 
directly backward. In femoral hernia the pressure 
should always be backward in order to close the 
crural ring. 

In oblique inguinal hernia the pad should be 
placed over the internal ring and canal, and not 
over the external ring. In direct inguinal hernia, 
on the other hand, the pad must be over the exter- 
nal ring. In femoral hernia, when the crural arch 
is natural and not relaxed, a small pad may be ap- 
plied over the neck of the sac ; but, when the arch 



94 A PLEA FOR THE CURE OF RUPTtJRE. 

is relaxed, the pad should lie upon the ligament 
itself. This latter rule should always apply to a 
femoral hernia that has been relieved by herni- 
otomy. There is one other point that is often 
forgotten, although it would seem to be almost 
self-evident to a good student of anatomy. The 
pads of a truss should always lie above the pubic 
bones, because both the inguinal and femoral rings 
lie above these bones. 

To test the value of a truss for any given hernia, 
the patient should be made to cough and strain, 
and, when possible, to jump ; but I would not have 
him do this often and again to satisfy his own 
curiosity. Such a course is very reprehensible and 
dangerous, besides accomplishing no possible good. 
After a competent surgeon has decided that the 
truss is well adapted to the case, and properly 
fitted, he should instruct the patient in its proper 
use. He should inform him, that so long as the 
hernia fails to descend, or cause a dragging feeling 
in the groin, so long is the truss efficient ; and he 
should warn him against useless experiments fool- 
ishly designed to test the value of the support. 

To measure for a truss, the circumference of the 
pelvis, taken one inch below the crest of the ilium, 



A PLEA FOR THE CURE OF RUPTURE. 95 

should be given, also the girth of the body begin- 
ning and ending at the hernial orifice, and the dis- 
tance from the hernial opening to the iliac spine. 
It is well, also, to indicate to the instrument-maker 
the directions in which the pad is intended to 
press ; and these directions should be determined by 
digital examination while the patient is standing. 
Patients who have laborious occupations should 
have two trusses, — one for ordinary wearing, and 
the other for occasions when extra exertions must 
be made. It is safe, also, to have an extra truss 
on hand, especially when travelling, so as to provide 
for accidental breakage of the truss that is worn. 

Of course there are many intricacies in the ad- 
justment of a truss that have not been explained 
here. They can be learned only by experience and 
good judgment on the part of the surgeon. What 
I have endeavored to do is to outline the most 
important rules that are of value in every-day 
practice. 

A few words to the wearer of a truss. It is abso- 
lutely necessary that the supporter should always 
be upon the body whenever the person is in the 
erect position. It were well, indeed, if this could 
be worn continuously, by night as well as by day ; 



96 A PLEA FOR THE CURE OF RUPTURE. 

but, if it be found inconvenient or uncomfortable to 
wear it in bed, it may be removed after the wearer 
has assumed the horizontal position. Never, how- 
ever, should he allow himself to rise from this 
horizontal position before he has properly applied 
his truss. 

These precautions may seem to some too strict, 
but it is only by attending carefully to them that 
the full value of the truss can be obtained. It 
may be that for months the wearer may, without 
any accident, arise from bed to the erect position, 
holding the hernia up by the fingers, and then 
applying the truss ; but there will always be the 
immediate danger that some time the hernia will 
in this way partially descend, become strangulated 
before the patient is fully aware of his danger, and 
entail upon him the most fearful consequences. 
More than this, no one can by any possibility cal- 
culate when this time may come. The best rule, 
then, is the rule of precaution. The patient should 
always apply his truss to his hernia before he has 
assumed the erect position, and should never re- 
move it so long as he remains in that position. 



A PLEA FOR THE CURE OF RUPTURE. 97 



PART VI. 

CAUSATION OF HERNIA. 



In considering the causation of hernia, three 
factors are to be taken into account; viz., — 

1. The containing or retaining parts. 

2. The contained parts. 

3. The causative force, active or passive. 

Containing or Retaining Parts. — The abdomi- 
nal cavity may be compared to a cylinder closed 
at the top and bottom. The diaphragm forms 
the cover, and by its movements increases or 
decreases the size of the cavity. A portion of 
the circumference of the walls of the cavity is 
rigid and firm, but by far the greater portion 
is yielding. The bottom of the cavity is formed 
by the perineal region and the pelvis. These 
walls are made up of skin, muscle, fascia, perito- 
neum, and bone; the number and quantity of each, 



98 A PLEA FOR THE CURE OF RUPTURE. 

as well as the absolute and relative arrangement, 
varying with the locality. 

If the tissues forming the walls were in all 
places continuous and of equal thickness, the viscera 
could only escape the proscribed limits by a forcible 
breach of continuity. It is owing to the mistaken 
idea that such a breach of continuity does occur, 
that the word " rupture " or " breach " is commonly 
applied to hernia. In reality, a direct rupture of 
the walls rarely occurs. If it does occur, it is the 
consequence of traumatism (punctured wounds, as 
those of a knife, spear, arrow, or some similar 
article, gunshot wounds, blows or falls), or as a 
result of disease (abscess), causing inflammation, 
ulceration, or suppuration. The breach of con- 
tinuity may take place from without inwards (ab- 
scess, suppurating bubo), or from within outwards 
(peritonitis, perityphilitis), and may be partial or 
complete ; the size of the tumor, as well as the 
amount and character of the displaced viscera, 
directly depending upon the depth, extent, and 
location of the wound. The formation and the 
causation of traumatic hernia is sudden, and easily 
understood, as we have active and present causes. 

Cases of traumatic hernia are, as has been stated, 



A PLEA FOR THE CURE OF RUPTURE. 99 

very rare ; and the majority of hernioe are due to a 
protrusion of the viscera through breaches of con- 
tinuity in the containing walls normally existing 
as such, but only abnormally existing as open rings 
or canals. These openings serve, — 

1. For the passage of vessels and nerves, as the 
spermatic cord in the male, and the round ligament 
in the female in the inguinal canal ; the passage of 
the femoral vessels and nerves in the femoral or 
crural canal ; the umbilical vessels in the umbilicus 
in fcetal life ; the aorta and nerves in the aortic 
opening in the diaphragm. 

2. For the passage of food into the body, and 
the passage of excrement from the body, — the 
oesophageal in the diaphragm ; the meatus urina- 
rius, for passage of urine ; the anus, for passage of 
faeces. In addition, the vagina forms in the female 
a very large and important opening. 

In addition to these, the presence of foramina 
(obturator foramen, etc.) must be recognized ; but 
these are normally closed by the tissues traversing 
them and by membranes across them, so that 
hernia through these is due to direct rupture of 
the covering parts. 

Inasmuch as these weak points exist in every 



100 A PLEA FOR TEIE CURE OF RUPTURE. 

normally formed person, all are in a degree pre- 
disposed to hernia ; but, unless abnormal factors 
are brought to bear, hernia does not occur, inas- 
much as the walls of these openings are closely 
applied to the contained tissue, so that the canal 
is never normally open, and exists as a canal only 
in name. 

These abnormal factors are : — 

1. Passive decreased power of retention, due 
to congenital malformation or to predisposition, 
hereditary, or acquired by injury or disease. 

2. Active increased pressure of viscera, tend- 
ing to force the viscera through the weakened 
points. 

These two may act alone, but usually act in 
unison. 

The foetus in titer o may be affected with hernia 
as a result of retarded development, and failure of 
the constructive process. This commonly occurs 
at the umbilicus as congenital umbilical hernia, 
and in this case the intestine and other viscera 
may never have been within the abdomen. The 
development at the umbilicus may be normal, but 
the birth may be retarded from causes depending 
on either the mother or child ; and the excessive 



A PLEA FOR THE CURE OP RUPTURE. 101 

pressure brought to bear upon the child by the 
mother's efforts in parturition may cause hernia. 
The mother may affect the child, and predispose 
it to hernia, by disease acquired before or after 
conception. Such predisposition is usually due to 
non-development, the result of insufficient (anaemia) 
or perverted (syphilis, cancer) nourishment. The 
accoucheur may cause a hernia by cutting the cord 
too short, for in many cases the bowel projects 
some distance into the cord. 

Normally, the umbilicus should be closed by a 
firm cicatrix at the end of four months ; but the 
ring may remain open, or be insecurely closed, 
causing hernia later in life, if not during infancy. 
Inflammation or suppuration may ensue after birth, 
and a troublesome hernia result. 

The inguinal canal may fail to close, and hernia 
be allowed. The peritoneum may fail to seal the 
canal through which the testis descended, and a 
congenital inguinal hernia may be allowed (vaginal 
when the whole canal is left open, and funicular 
when the canal is partially closed). A retained 
testicle may simulate hernia. Hernia, as a rule, 
if occurring during early childhood, occurs on the 
side on which the testicle descended last (the right). 



102 A PLEA FOR THE CUKE OF RUPTURE. 

In early life the two rings of the ingninal canal 
are nearly apposed, and a hernia at this time very 
much resembles a direct hernia of adult life. As 
development goes en, the internal ring recedes and 
ascends, making the inguinal canal, which at first 
did not exist. If the hernia can be retained, the 
natural process of development will, it is evident, 
tend to close the canal against the descent of the 
viscera. A truss, therefore, may, in such a case, 
aid the result by maintaining the viscera in the 
abdomen ; but it can exert no curative effect, being 
simply accessory to natural processes. In old age 
the reverse process goes on where a hernia has 
existed for a long time, the rings approaching each 
other instead of receding. It is evident that a 
truss does not have the same aid from nature as 
in the former case, and it cannot effect a cure 
unaided. 

Before puberty, the child is more liable to hernia 
than later. In addition to the greater risk of in- 
jury incurred, the diseases of childhood have a 
direct influence in weakening the retaining parts, 
and also in increasing the active agents. Most 
important in this regard are whooping-cough and 
croup, and all diseases characterized by, or at- 



A PLEA FOR THE CURE OF RUPTURE. 103 

tended with, convulsions. Syphilis, rickets, struma, 
tuberculosis, and hip-disease may cause hernia. 

Deformities, especially those of the spine and 
femur, are productive of hernia, as they directly 
weaken the system, and throw the weight of the 
viscera against parts not intended or adapted to 
sustain them. Naturally, the weight of the viscera 
falls into the pelvic cavity ; and any agent tending 
to change the direction of the weight and pressure 
is injurious. 

During the period from twelve to twenty years, 
the body is in its full vigor, and hernia is least 
likely to occur during this period. 

In adult life the body is naturally deteriorating, 
and this natural decline is aided by errors in dress, 
diet, and occupation, by abuse of the natural func- 
tions, and by accident or disease. 

Other things being equal, inguinal hernia is 
more common in man, owing to the larger size 
of the inguinal rings. Femoral hernia is more 
common in women, owing to the deeper and wider 
femoral arch and the smaller muscles in the space. 
Owing to the presence of the uterus, woman is less 
liable to hernia of any kind than man, since the 
uterus acts in a degree as a compensating balance 



104 A PLEA FOR THE CURE OF RUPTURE. 

of forces. Hernia in the perineal region, however, 
is more common in woman, owing to the laxity of 
the tissues. 

Errors of dress are those where the abdomen is 
tightly constricted and the space decreased by tight 
waist-bands or belts, and by corsets or abdominal 
supporters. High-heeled shoes, too, may aid in the 
causation, — directly, by diverting the direction of 
pressure of the viscera ; or, indirectly, by tripping 
the wearer up, and wrenching the body. Errors 
in diet are those where an insufficient amount of 
nourishment is taken, causing a weakening of the 
abdominal walls. This may be unavoidable, owing 
to poverty, or to diseases causing loss of appetite. 
The diet may be too constipating, and cause strain- 
ing at stool, and, as a result, hernia ; or it may be 
too laxative, and be as injurious. Debauchery, 
resulting in enervation and constitutional trouble, 
is a common cause of hernia. This is especially 
the case with prostitution and libertinism, o wing- 
to the diseases induced thereby. 

Diseases predisposing to hernia are those causing 
great depression of the vital forces, and attended 
with or followed by injurious complications. Such 
are typhoid-fever, anaemia, leucocythsemia, yellow- 



A PLEA FOR THE CURE OF RUPTURE. 105 

fever, diphtheria, etc. Diseases of the air-passages, 
especially where breathing is interfered with, or 
where there is constant congh or dyspnoea, may 
have a direct influence. Some diseases of the 
heart, causing dyspnoea, may be considered. Dis- 
eases accompanied with tenesmus, as dysentery, 
and those accompanied with vomiting, as yellow- 
fever, are active as well as passive. 

In considering diseases of the abdominal organs, 
it may be stated at the outset that any disease 
resulting in hypertrophy of an organ or in a neo- 
plastic growth may be a cause of hernia by de- 
creasing the capacity of the cavity, and at the same 
time increasing the pressure. Atrophy may act in 
a negative way. Abscess of various organs may 
follow inflammation, and the pus may burrow 
through the abdominal walls. Peritonitis may 
ensue, or may extend by contiguity from an in- 
flamed organ. This is very likely to happen near 
the uterus and adjacent organs. Gastritis is an 
active as well as passive agent, on account of the 
vomiting attending it. Enteritis may be indirectly 
concerned. Constipation and diarrhoea are not 
to be overlooked. Prolapsus ani, fistula in ano, 
hemorrhoids, external and internal, and fissure or 



106 A PLEA FOR THE CURE OF RUPTURE. 

stricture, must be considered as active causes. In 
short, any cause tending to weaken the abdominal 
walls, and to decrease the resistance from without, 
— the pressure from within not being correspond- 
ingly decreased, but remaining normal or being 
increased, — or any cause tending to increase the 
pressure from within, — the resistance not being 
correspondingly increased, but remaining normal or 
being decreased, — may cause hernia. Decreased 
resistance of the abdominal walls, and increased 
pressure upon the abdominal walls, acting sepa- 
rately or in unison, may cause hernia. If the re- 
sistance is increased with the pressure pro rata, 
the hernia will not occur as a rule, but may occur 
in consequence of stretching ; or, as is sometimes 
the case, long-continued and constant pressure may, 
after a while, tire out the resisting muscles, and so 
overcome the resistance. 

To understand the rationale of the causation of 
hernia, the comparison of the abdomen to a cylin- 
der, having weak points in its walls and closed at 
the top with a shifting cover, must be kept in 
mind. Normally, the rise and fall of the dia- 
phragm is attended by compensatory movements of 
the abdominal walls ; and the movements of one 



A PLEA FOR THE CURE OF RUPTURE. 107 

are counterbalanced by those of the other, so that 
the relation of pressure and resistance is main- 
tained equal. The pressure in the abdominal 
cavity may be increased by engorgement of the 
viscera (stomach with food, bladder with urine, 
rectum with faeces), or by enlargement of the vis- 
cera, due to disease (congestion, hypertrophy) or 
to neoplastic growths. Since the muscles compris- 
ing the abdominal walls serve as motors as well as 
retainers, there is necessarily a greater amount of 
resistance in the abdominal walls than is necessary 
to resist the internal pressure. Accordingly the 
pressure may be increased beyond the normal 
limits, and yet not cause- hernia, provided that 
the abdominal walls are not weakened ; but if the 
pressure is constant so as to tire out the resist- 
ance, or if the whole constitution is involved, or if 
the pressure increases beyond the power of resist- 
ance, the tissues can no longer retain the viscera, 
and a hernia may occur. 

The amount of resistance, therefore, is an impor- 
tant factor, as well as the amount of pressure ; for 
increased and varying pressure is guarded against 
by an extra amount of resistance over and above 
that required to counterbalance the normal press- 



108 A PLEA FOR THE CURE OF RUPTURE. 

ure: but, if the resistance is weakened, there is no 
safeguard, since the pressure is not decreased, but 
is relatively increased, although absolutely normal. 

The recent and assigned cause is seldom suffi- 
cient by itself to account for a hernia. The as- 
signed cause, as a rule, acts upon parts already 
weakened by injury or disease ; and this weaken- 
ing of the retaining parts may be the result of 
several forces acting consecutively or in conjunc- 
tion. For this reason, in recording the causation 
of a case of hernia, the past history of the patient 
must be considered, especially as regards disease of 
a wasting type, or characterized by convulsions, 
vomiting, tenesmus, excessive cough, etc. Family 
history is of importance, especially in regard to 
history of disease which is hereditary. 

Present and previous occupations should be defi- 
nitely recorded. Occupations requiring straining 
efforts are especially productive of hernia ; but, on 
the other hand, those in which no bodily exertion 
is required may, by the lack of exercise, predispose 
to hernia. Occupations requiring pressure upon 
the abdomen by tools or weights are to be con- 
sidered. 

The present state of health of the patient may 



A PLEA FOE THE CURE OF RUPTURE. 109 

be of interest, and several questions have been in- 
serted relating to this. Aside from questions of 
causation these may have a direct bearing on the 
treatment and its results. 

To enumerate all the diseases that might predis- 
pose or actually produce hernia would be an end- 
less task. A few of the more important ones have 
been tabulated ; but many have been omitted which 
no doubt may cause hernia indirectly, and many 
have been inserted which may have no connection. 
Any one who has attempted to draw up such a 
form will understand the difhculty of deciding 
what shall be kept and what discarded. 

The remarks on the causation of hernia are in- 
tended more as suggestions than as dogmatic state- 
ments. For the purpose of obtaining stastistics on 
the subject a table has been prepared, and is here 
inserted. I shall be pleased to furnish these tables 
to any one willing to aid me in this purpose. In 
using the accompanying diagram, the outline-figure 
is to be superimposed over the diagram, the crosses 
on each coinciding. The situation of the various 
kinds of hernia will then appear on the outline- 
figure, and the required record can be made with 
ink. This plan has been applied by me to other 



110 



A PLEA FOR THE CURE OF RUPTURE. 



portions of the body, as the thorax for recording 
heart and lung trouble, and the bones for record- 
ing fractures. 

The size of the hernia should be recorded in 
definite figures, stating the circumference at the 
base and the distance over the tumor in two direc- 




THE CONFORMATEUR. 



tions at right angles to each other. The contour 
may be recorded by using a strip of lead, or, 
more easily, by the " conform ateur," an instrument 
which I have used in many cases besides hernia. 
This was made for me by George Tiemann & 
Co., and consists of a frame composed of hard 
rubber sides, between which is a soft rubber lin- 
ing. Through this soft rubber lining a number of 



A PLEA FOR THE CURE OF RUPTURE. Ill 

small steel wires play freely when pressure is ap- 
plied, but are held in position by the soft rubber 
when the pressure is removed. In use this is 
placed perpendicularly over the tumor, and the 
frame gently pushed down. The wires will then 
adapt themselves to the outline of the swelling or 
deformity, and the contour may then be transferred 





to paper by laying the instrument on its side, and 
carrying a pencil along the ends of the wire. 1 

It is quite essential that the diagnosis of hernia 
should be correctly made before the causation is 
discussed. Rules cannot be laid down for all cases. 
The size, shape, consistency, definition, mobility, 
condition of skin, pain, tenderness, fluctuation, pul- 
sation, translucency and cough-impulse, must all 

1 The figure of the pin inserted with the conformateur (referred 
to on a previous page) will be found of use in applying the bandages 
in the treatment of hernia, or other ca^es requiring the occasional 
unfastening of the bandage. They were first used by me in October, 
1881. I have found them of especial advantage in applying the obstet- 
ric binder. c. e. w. 



112 A PLEA FOR THE CURE OF RUPTURE. 

be considered to make a differential diagnosis. 
Having clearly ascertained these, the accompany- 
ing tables may be of some service in deciding the 
question ; bnt there are many obscure cases where 
there must always be more or less doubt, since 
the symptoms are so vague or confused that no 
decision can be positively made. In such cases 
the history is an invaluable aid in clearing up 
matters. 





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A PLEA FOR THE CUKE OF RUPTURE. 113 



HERNIA. 

CAUSATION, TREATMENT. 

Please return this card, when filled, to 

JOS. H. WARREN, A.M., M.J)., 

51 Union Park, Boston, Mass., U.S.A. 

The answers to questions in heavy-faced type may be 
given by drawing a line through superfluous words. An- 
swers to those questions printed in light-faced type are to 
be written over the question. 

Observer s name. 

Residence, No. Street. 

City or Town ; County or State. 

Date. No. 

Name of patient. Age. Male, female. Single, 
married, widowed. Nationality. Occupation ; how 
long followed. Previous occupation, if any. 

Previous illness. Enumerate in sequence. 

Previous injuries. 

Place of residence: high, low; damp, dry; exposed, 
confined. Food: insufficient; meat, vegetable, or ce- 
real diet predominates. Intemperate, total abstainer. 
Strong, moderate, weak. Dark, fair. Growth : rapid, 



114 A PLEA FOR THE CURE OF RUPTURE. 

moderate, slow, retarded. Stature : tall, medium, 
short. Form: full, spare, obese, emaciated. General 
condition : good, fair, poor. Deformities : hereditary, 
congenital; acquired by habit, accident, or disease. 

Respiration: deep, shallow; abdominal, thoracic. 
Menstrual history, if a female: irregular; dysmenor- 
rhea, ainenorrhoea. 

Nutritive system. Nervous system. Respiratory sys- 
tem. Osseous system. Muscular system. Circulatory 
system. Urinary system. Reproductive system. 

Constitutional disease : syphilis, cancer, scrofula. 
Hereditary disease. Present state of health. Dress : 
corsets, belts, tight waistbands. Abdominal tumors : 
ascites, distended bladder, tympanites. Solid tumors. 
Faeces. Liver. Spleen. Cancer. Kidney. Cys- 
tic kidney. Floating kidney. Peri typhli tic abscess. 
Retained testicle. Phantom tumor. Uterine. Ova- 
rian. Parovarian. Hip disease. Spinal disease; ca- 
ries, kyphosis, lordosis, scoliosis. Abscess of the hip. 
Anchylosis. Dislocation of femur : dorsal, sciatic, 
obturator, pubic. Talipes equinus, calcaneus, varus, 
valgus. Fevers : yellow, typhoid, scarlet. Diphtheria. 
Rheumatism. Gout. Elongated uvula. Pharyngitis. 
Abscess of pharynx. Whooping cough. Coryza. 
Laryngitis. Croup. Ulcer of larynx. Abscess. 
(Edema. Necrosis. Stricture. Polypus. Bronchitis: 
acute, chronic, capillary. Pneumonia. Abscess of 
lung. Gangrene. Active or passive congestion. Apo- 
plexy. CEdema. Cirrhosis. Emphysema. Atelectasis. 
Phthisis. Pleurisy. Empyema. Pneumothorax. Hy- 
drothorax. Mumps, metastatic to testicle. (Esopha- 
gi tis. Stricture. Dysphagia. Gastritis. Dilatation of 
stomach. Chronic ulcer. Cancer. Stricture of cardia, 



A PLEA FOR THE CURE OF RUPTURE. 115 

of pylorus. Dyspepsia. Gastralgia. Pyrosis. Duode- 
nitis. Enteritis. Typhilitis. Dysentery. Diarrhoea. 
Cholera morbus, infantum. Ulceration of intestine. 
Obstruction of bowels from substances in bowels; from 
tumor, stricture, intussusception, twisting-, strangula- 
tion. Colic: flatulent, bilious, lead. Perihepatitis. 
Hepatitis: acute, chronic. Abscess. Atrophy. Con- 
gestion. Cirrhosis. Fatty degeneration. Lardaceous 
degeneration. Cancer. Jaundice. Inflammation of 
hepatic ducts. Fistula. Obstruction. Cancer. Biliary 
calculi. Splenitis. Abscess. Enlargement due to ma- 
laria. Hypertrophy. Lardaceous spleen. Tubercle. 
Nephritis. Perinephritis. Pyelitis. Fatty degenera- 
tion. Amyloid degeneration. Hydronephrosis. Hy- 
pertrophy. Atrophy. Cancer. Calculus. Cystitis. 
Dilatation. Sacculation. Inversion. Extroversion. 
Stone. Paralysis. Spasm. Prostatis: acute, chronic. 
Abscess. Hypertrophy. Atrophy. Cancer. Tubercle. 
Calculus. Stricture of urethra: organic, traumatic, 
spasmodic, inflammatory. Purpura. Scurvy. Pleth- 
ora. Anaemia. Leucocythemia. Pyaemia. Chlorosis. 
Retention of urine due to inflammation caused by 
gonorrhoea, drink, or exposure to cold; by organic 
stricture ; by congestion of the prostrate ; by atony of 
bladder due to over distension, to paralysis, impacted 
calculus. Hysterical retention. Gravid or displaced 
uterus. Phimosis. Balanitis. Gonorrhoea. Paraphi- 
mosis. Sores: syphilitic or non-syphilitic. Scrotum. 
Extravasation. CEdema. Elephantiasis. Epitheli- 
oma. Testicle. Acute orchitis. Sarcocele. Syphilis. 
Tubercule. Chronic inflammation. Hernia of testis. 
Hydro-sarcocele. Malignant tumor. Adherent nym- 
phse. Noma. Vascular urethra. Labial hemato- 
cele. Labial cyst. Labial abscess. Venereal sores. 
Mucus tubercles. Warts. Epithelioma. Elephanti- 



116 A PLEA FOR THE CURE OF RUPTURE. 

asis. Hemorrhoids : external, internal. Prolapsus ani. 
Polypus, lschio rectal abscess. Fistula in a no. Stric- 
ture. Fissure. Schirrus. Tumor of testicle involving" 
skin spermatic veins tunica veginalis testicle epididy- 
mis or cord. Extending* up to the external abdominal 
ring. Impulse on coughing. Reducible into abdomen. 
Non-translucent. Weight. Consistence. 



RECORD OF CASE. 

Duration. Congenital. Acquired. Assigned cause. 
Probable cause. Form of Hernia : original, right, left, 
direct, oblique, complete, incomplete, scrotal, labial. 
Femoral, right, left. Umbilical. Ventral. Irreducible, 
incarcerated, strangulated. Local symptoms and signs: 
pain, tenderness, fluctuation, pulsation, translucency, 
cough impulse, consistency, definitions, mobility. Size 
in definite figures. Constitutional symptoms. Gen- 
eral debility : nausea, vomiting, diarrhoea, constipation. 
Hernia retained : simple bandage, elastic belt, spring 
truss. Give name of truss worn. Hernia cannot be 
retained. 

TREATMENT AND PROGRESS OF CASE. 

In as brief a manner as possible describe the method 
and instrument used, — by name, if in common use; 
by detail, if not commonly known, — giving any modi- 
fications that may be adopted, and instrument used if 



A PLEA FOR THE CURE OF RUPTURE. 117 

injection is made. Mention the steps of the operation 
and dressings applied. Afterwards record each day: 
the pulse, temperature, and respiration ; the treatment 
and diet ; the condition of the parts in question ; the 
amount of swelling and inflammation ; the amount and 
character of discharge ; the period of granulation and 
the time of removal of sutures or ligatures ; the forma- 
tion of abscess : the date of discharge and of cure. 

REMARKS. 



Right. 



Left. 



1 


2 


3 


4 


5 
X 


6 


7 




9 



8 
F F 



e. &. w 



Figures refer to regions; letters, to hernise. O, Inguinal hernia; 
F, Femoral hernia; X, Umbilical hernia; 1,3, Hypochondriac region; 
2, Epigastric; 4, 6, Lumbar region; 5, Umbilical; 7, 9, Inguinal re- 
gion; 8, Hypogastric. 



iOTJS 



.USED 

c. 



No) 



OPERATION- BY STJBCTJTA.N-KOXJS INJECTION. 



Nu 


siber OF Case. 


iNGUlNAL.jDlBECT. 


Oblique. 


Right Side. 


Left Side. 


Femoral. 


Right. 


Left. 


Umbilical. 


Duration. 


Congenital. 


AC„ 


Single. 


Double 


MALE. 


FEMALE 


I 


DATE. 


Formula used 
A, B, C. 


Truss 
Di 


PENSED L W S i™ POnT 


Occupation. Cured. Relievei 


DJte. Remarks. 




E. CHI. . . 


- 


- 


- 


- 


- 


Femoral. 


Right. 


- 


Umbilical. 


6 years. 


- 


Acquired. 


Single. 


- 


- 


Female. 


55 


Feb., 1880 


B. 


None wo 


rn for 2 years . . . 


Housewife 


Cured 


- 


May, 1883 


This was a small rupture, but very painful ; oiieu became sirangulatcd. 




7, CIV. • • 


- 


- 


- 


- 


- 


- 


- 


- 




20 " 


- 






- 


- 


" 




.02 


" 1880 


C. 




for 3 " . . . 






" 


" 1883 


Ilii was a very large rupture, caused by chlUl-bcarlng; became strangulated 




D. CV. . . . 


Inguinal. 


- 


Oblique. 


Eight side. 


- 


- 


- 




- 


3 " 


- 








- 


Male. 


- 


26 


" 18S0 






for2 " . . . 


President uf MaiiufueUirin;, 

Company. 
Clerk. 




- 


" n8S3 


Thi- was a medium-sized rupture, caused by lifting; became **t r:m^ul;i1eil oi.ee. 




H. CVI. . . 




- 




- 


Left side. 


- 




- 


- 


10 " 


- 








- 






- 


32 


March,1880 






fori year . . . 




- 


" 1883 


This was il very large rupture, caused by long illness arid dyspepsia. 


Dl 


11. CVII. . • 




- 






- 


- 


- 


- 


- 


25 " 


- 






" 








- 


52 


18S0 






for 1\ years . . 


Physician 




- 


" 1883 


This was a small rupture, caused by running and leaping. 




L. CV1II. . . 




Direct. 


- ' 


- 




- 


- 


" 


- 




- 








- 






" 


40 


April, 1880 






for 2 " . . 


Civil Engineer .... 




" 


" I883 


This was a very large niplure on left Hide, small on riglil , docs not know cause, 
strangulated live times. 




w.crx. . . 


«' 


- 






- 


- 


- 


- 


- 


2 years. 


- 






- 


Double. 






- 


24 


" 1880 






foi-2i " . . 


Teacher ....... 




" 


" 1883 






w. ex . . . 




_ 




. 




- 


- 


- 


- 


5 " 


- 








- 






- 


31 


May, 1880 






forlj " . . 


Architect 




- 


" 1S83 


Tills was a large rupture, caused by illness and great emaciation. 




S. CXI. . . 




- 




- 


« 


- 


- 


" 




1 year. 


- 








- 








22 


" 188 ° 






for 1 year . . . 


Student 




- 


" 1SS3 


This was a large niplure on right side, small mi [eft; do QOt know cause, 
liecaiili' strangulated r 




H. CXII. . . 


u 




_ 




- 


- 


- 


- 


- 


40 years. 


- 






- 








- 


64 


1880 


B,C. 




for 2 years. . . 


Agent of railroad . . . 




- 


" 1883 


This was nut a very large niplure, ealised by lilting. 




C. CXHI. . . 




. 




. 




_ 


- 


- 


- 


3 or 6 " 










- 






- 


43 


June, 1880 


C. 




forlj " . . . 


Farmer 




- 


" 1S83 


These were a large and a small rupture; do tml know cause. 




D. CXIV. . . 












_ 


- 


- 


- 


1 year. 


- 






- 








- 


25 


Sept., 1880 






for 1 year . . . 


Clerk 




- 


" 1883 


This was a large rupture, caused by ovcr-strainlng. 




E. CXV. ■ ■ 




_ 






_ 


_ 


- 


- 


- 


7 years. 


- 








- 






- 


33 


" 1880 






for \\ years . . 


Painter 




- 


" 1883 


This was a medium-sized rupture; do not know the cause. 




P. CXVI. . . 






_ 




- 


. 


- 


- 




4 " 


- 








- 






- 


44 


" 1SS0 






fori year . . . 


Clergyman 




" 


" 18S3 - 


This was a large rupture on left side, small on right; do not know tin- cause. 
Ii';iligulaled eight nr nine times. 


D 


d cxvn 












_ 


_ 


- 


- 


38 " 


- 






- 








- 


38 


Nov., 1880 






fori » . . . 


Physician 




- 


" 1883 - 


Tlii.- was a large rupture, canned by stepping down from sidewalk. 


g. cxvin. . 












_ 


. 


- 




5 " 


. 








- 






- 


54 


De(h, 1880 






fori " . . . 


Retired merchant .... 




- 


" 1SS3. 


This was a small rupture on left side, large on right side, caused by railroad 




w. cxix. . . 




- 






- 


" 


" 






2 " 


- 






" 








" 


37 


1881. 






for H years . . 


Lawyer 

Physician 






" 1S83. 
" 1883. 


This was a medium. sized rupture, caused by horse-railroad accident. 
This was a very small rupture. 


D 


.w. cxx. . . 

L. CXXI. . . 










„ 


" 


- 


- 


- 


1 year. 


- 








- 






- 


5 








for 1 year . . . 


Child 






" 1883. 


This was a small rupture, but very painful. 




\v. exxn. . 












. 


_ 


- 




6 mths. 


- 








- 






- 


27 


March, 1881. 






for 1 " ... 


Student 




- 


No report. 


This was a small rupture. 




F. CXX1II. 












. 


_ 


- 




3 years. 


- 








- 






- 


31 


" 1881. 






for 1J years . . 


Bank-clerk 




- 


May, 1883. 


This was a rupture not larger than an English walnut. 




b. exxrv. 
















- 




2 " 


- 








- 






- 


33 


April, 1881 






fori year . . . 


Farmer 




" 


" 1883. 


Thlfl was a small rupture. 




J.CXXV. 
G. CXXTI. 




- 


" 




- 


" 


- 


" 




H " 


" 








: 






" 


46 

44 


1881 




Wears tr 


iss, but no need of it. 


Sea-captain 

Seaman 




- 


" 1883. 


This was a medium-sized rupture. 
This was a medium sized rupture. 




M.cxxvn. 




" 






- 


" 


- 




" 


ill 


- 








- 








■60 
21 


June, 1881 
1S81. 




None wo 


for 14 years . . 


Gentleman 

Carpenter 






« » 


This was a very large rupture. 
This was a small rupture. 




B. CXXVIII. 
F. CX XIX. 

v. exxx. 






- 


- 


" 


" 


" 


- 


" 


7 years. 


- 


" 


- 


■ 


" 


- 


45 
35 


July, 1881. 




" 




Peddler 

Laborer 




" 


» 1883. 
» 1883. 


This was a large rupture. 



INDEX. 



Bandage-pin, 75, 111. 

Causation of hernia, 97. 
Clinical cases, 47, 86. 
Cohnheim's theory, 12. 
Conformateur, 110. 

Fibrous tissue, Stability of, 33, 41. 
Formulae, 57. 

Galvano-cautery operation, 84. 

Historical sketch, 02. 

Inflammation, Theories of, 7. 

Operations: — 

Closure of sac, 27. 
Galvano-cautery, 84. 
Heaton's, 24. 
Injection of sac, 29. 
Wood's, 26. 

Plastic lymph theory, 9. 
Proliferation theory, 12. 

Quercus alba, Action of, 31. 
Quercus alba, Fl. ext. of, 65. 



Record of cases, Form of, 113. 
Repair by first intention, 16. 
Repair by granulation, 19. 
Repair, Laws of, 22. 



Stability of fibrous tissue, 33, 41. 
Stricture of urethra, 36. 
Subcutaneous operation: — 

Synopsis of, 53. 

Method of, 55. 
Subcutaneous repair, 16. 
Syringe for operation, 46. 



Tendinous irritation, 24. 
Theories of Repair: — 

Cohnheim's, 12. 

Granulation, 19. 

Quercus alba, 31. 

Plastic lymph, 9. 

Proliferation, 12. 

Subcutaneous, 16. 

Tendinous irritation, 24. 
Tissue organization, 13. 
Tissue resolution, 14. 
Truss, Anatomical, 46. 
Truss, Proper fitting of, 91. 



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